Provider Demographics
NPI:1598276404
Name:BALBOA NEPHROLOGY MEDICAL GROUP,INC.
Entity Type:Organization
Organization Name:BALBOA NEPHROLOGY MEDICAL GROUP,INC.
Other - Org Name:SAN DIEGO ACCESS AND SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR & AO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:NAMAZY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-582-4490
Mailing Address - Street 1:4225 EXECUTIVE SQ STE 450
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-8411
Mailing Address - Country:US
Mailing Address - Phone:858-810-0000
Mailing Address - Fax:
Practice Address - Street 1:6402 EL CAJON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-2645
Practice Address - Country:US
Practice Address - Phone:619-582-4490
Practice Address - Fax:619-582-4737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical