Provider Demographics
NPI: | 1700342748 |
---|---|
Name: | SAN DIEGO UPTOWN PEDIATRIC MEDICAL GROUP, INC |
Entity Type: | Organization |
Organization Name: | SAN DIEGO UPTOWN PEDIATRIC MEDICAL GROUP, INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PHYSICIAN/CO-PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | HILARY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | KRAUSE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 619-295-3911 |
Mailing Address - Street 1: | 3500 FIFTH AVE STE 101 |
Mailing Address - Street 2: | |
Mailing Address - City: | SAN DIEGO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92103-5020 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 619-295-3911 |
Mailing Address - Fax: | 619-295-4356 |
Practice Address - Street 1: | 3500 FIFTH AVE STE 101 |
Practice Address - Street 2: | |
Practice Address - City: | SAN DIEGO |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92103-5020 |
Practice Address - Country: | US |
Practice Address - Phone: | 619-295-3911 |
Practice Address - Fax: | 619-295-4356 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2019-02-14 |
Last Update Date: | 2019-02-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Single Specialty |