Provider Demographics
NPI: | 1710936372 |
---|---|
Name: | PIMG; A PROFESSIONAL MEDICAL CORPORATION |
Entity Type: | Organization |
Organization Name: | PIMG; A PROFESSIONAL MEDICAL CORPORATION |
Other - Org Name: | CENTRE FOR HEALTHCARE |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PRESIDENT OF BOARD |
Authorized Official - Prefix: | |
Authorized Official - First Name: | STUART |
Authorized Official - Middle Name: | NATHAN |
Authorized Official - Last Name: | GRAHAM |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 858-613-8900 |
Mailing Address - Street 1: | PO BOX 28199 |
Mailing Address - Street 2: | |
Mailing Address - City: | SAN DIEGO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92198-0199 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 858-613-8900 |
Mailing Address - Fax: | 858-618-1523 |
Practice Address - Street 1: | 15611 POMERADO RD |
Practice Address - Street 2: | SUITE 400 |
Practice Address - City: | POWAY |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92064-2437 |
Practice Address - Country: | US |
Practice Address - Phone: | 858-675-3100 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-05-09 |
Last Update Date: | 2009-07-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 133N00000X | Dietary & Nutritional Service Providers | Nutritionist | Group - Multi-Specialty | |
No | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Group - Multi-Specialty | |
No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2085B0100X | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | Group - Multi-Specialty |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 2085U0001X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
No | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
5254950002 | Medicare NSC | ||
CA | 5254950001 | Medicare NSC | |
CA | CU0284 | Medicare PIN |