Provider Demographics
NPI:1558483172
Name:MERCY ASSOCIATED PEDIATRICS SUBSPECIALISTS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MERCY ASSOCIATED PEDIATRICS SUBSPECIALISTS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RIAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MARDOUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-260-7046
Mailing Address - Street 1:PO BOX 33855
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3855
Mailing Address - Country:US
Mailing Address - Phone:619-401-4016
Mailing Address - Fax:
Practice Address - Street 1:4077 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2105
Practice Address - Country:US
Practice Address - Phone:619-260-7046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0057900Medicaid