PULMONARY MEDICINE & INFECTIOUS DISEASE MEDICAL GROUP

Provider Demographics

• NPI: 1619004421
• Name: PULMONARY MEDICINE & INFECTIOUS DISEASE MEDICAL GROUP
• Entity Type: Organization
• Organization Name: PULMONARY MEDICINE & INFECTIOUS DISEASE MEDICAL GROUP
• Authorized Official - Title/Position: PARTNER
• Authorized Official - Prefix: DR
• Authorized Official - First Name: EDWARD
• Authorized Official - Middle Name: C
• Authorized Official - Last Name: FEDERMAN
• Authorized Official - Credentials: MD
• Authorized Official - Phone: 619-462-9010
• Mailing Address - Street 1: 6699 ALVARADO RD
• Mailing Address - Street 2: SUITE 2308
• Mailing Address - City: SAN DIEGO
• Mailing Address - State: CA
• Mailing Address - Zip Code: 92120-5244
• Mailing Address - Country: US
• Mailing Address - Phone: 619-462-9010
• Mailing Address - Fax: 619-287-8165
• Practice Address - Street 1: 6699 ALVARADO RD
• Practice Address - Street 2: SUITE 2308
• Practice Address - City: SAN DIEGO
• Practice Address - State: CA
• Practice Address - Zip Code: 92120-5244
• Practice Address - Country: US
• Practice Address - Phone: 619-462-9010
• Practice Address - Fax: 619-287-8165
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2007-02-28
• Last Update Date: 2015-07-24

Provider Licenses

State	License ID	Taxonomies
CA		207RI0200X, 207RP1001X
CA	G15864	207RP1001X
CA	G60283	207RP1001X
CA	G70525	207RP1001X
CA	G78214	207RP1001X
CA	G70238	207RI0200X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207RI0200X	Allopathic & Osteopathic Physicians	Internal Medicine	Infectious Disease	Group - Multi-Specialty
No	207RP1001X	Allopathic & Osteopathic Physicians	Internal Medicine	Pulmonary Disease	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
CA	00G782140	Medicaid
CA	00A792460	Medicaid
	WG70238C	Medicare PIN
CA	00G782140	Medicaid
	BA510A	Medicare PIN
	W10388	Medicare PIN
	WA90413A	Medicare PIN
	H28008	Medicare UPIN
	H50293	Medicare UPIN
	WG78214A	Medicare PIN
	WG15864D	Medicare PIN
	F64928	Medicare UPIN
	WG70525C	Medicare PIN
	CN094Z	Medicare PIN