Provider Demographics
NPI:1801192497
Name:SOUTH BAY GERIATRIC AND INTERNAL MEDICINE INC
Entity Type:Organization
Organization Name:SOUTH BAY GERIATRIC AND INTERNAL MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MUSHRIK
Authorized Official - Middle Name:
Authorized Official - Last Name:KAISEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-426-9731
Mailing Address - Street 1:PO BOX 92191
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92191-0723
Mailing Address - Country:US
Mailing Address - Phone:619-426-9731
Mailing Address - Fax:619-426-9733
Practice Address - Street 1:340 4TH AVE
Practice Address - Street 2:#9
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-3813
Practice Address - Country:US
Practice Address - Phone:619-426-9731
Practice Address - Fax:619-426-9733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-31
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72963173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A729631Medicaid
CAA72963Medicare PIN
CA00A729631Medicaid