Provider Demographics
NPI:1558459180
Name:ADVANCED PEDIATRIC MEDICAL GROUP INC
Entity Type:Organization
Organization Name:ADVANCED PEDIATRIC MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:JALAL
Authorized Official - Last Name:SADRIEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-268-0702
Mailing Address - Street 1:5222 BALBOA AVE
Mailing Address - Street 2:SUITE 42
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-6991
Mailing Address - Country:US
Mailing Address - Phone:858-268-0702
Mailing Address - Fax:858-268-0374
Practice Address - Street 1:5222 BALBOA AVE
Practice Address - Street 2:SUITE 42
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6904
Practice Address - Country:US
Practice Address - Phone:858-268-0702
Practice Address - Fax:858-268-0374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46462261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0071320Medicaid