Provider Demographics
NPI:1609190529
Name:PACIFIC NEPHROLOGY GROUP A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PACIFIC NEPHROLOGY GROUP A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SALAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ISHAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-219-1161
Mailing Address - Street 1:995 GATEWAY CENTER WAY
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4500
Mailing Address - Country:US
Mailing Address - Phone:619-219-1161
Mailing Address - Fax:
Practice Address - Street 1:182 INDUSTRIAL RD
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:PA
Practice Address - Zip Code:17327-8626
Practice Address - Country:US
Practice Address - Phone:717-235-9352
Practice Address - Fax:717-235-4024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty