Provider Demographics
NPI:1578569497
Name:CHILDRENS MEDICAL GROUP
Entity Type:Organization
Organization Name:CHILDRENS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENFELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-744-6710
Mailing Address - Street 1:1582 W SAN MARCOS BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-4081
Mailing Address - Country:US
Mailing Address - Phone:760-744-6710
Mailing Address - Fax:760-744-6156
Practice Address - Street 1:1582 W SAN MARCOS BLVD STE 203
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-4081
Practice Address - Country:US
Practice Address - Phone:760-744-6710
Practice Address - Fax:760-744-6156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA015180208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ33912ZMedicaid