Provider Demographics
NPI:1295804003
Name:SAN DIEGO PSYCHIATRIC MEDICAL GROUP INC
Entity type:Organization
Organization Name:SAN DIEGO PSYCHIATRIC MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:RIVKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-565-1177
Mailing Address - Street 1:6265 CYPRESS POINT ROAD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120
Mailing Address - Country:US
Mailing Address - Phone:619-265-1560
Mailing Address - Fax:619-265-1562
Practice Address - Street 1:2780 CARDINAL ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:858-565-1177
Practice Address - Fax:858-565-0696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A33548Medicare UPIN
W608Medicare ID - Type Unspecified