Provider Demographics
NPI:1659349421
Name:PENN ELM MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PENN ELM MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:ALTSCHULER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-745-2000
Mailing Address - Street 1:488 E VALLEY PKWY
Mailing Address - Street 2:411
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3363
Mailing Address - Country:US
Mailing Address - Phone:760-745-2000
Mailing Address - Fax:760-745-0451
Practice Address - Street 1:488 E VALLEY PKWY
Practice Address - Street 2:411
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3363
Practice Address - Country:US
Practice Address - Phone:760-745-2000
Practice Address - Fax:760-745-0451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1400Medicare ID - Type Unspecified