Provider Demographics
NPI:1740347210
Name:CHILDREN'S SPECIALISTS OF SAN DIEGO - DIV OF ENDO
Entity type:Organization
Organization Name:CHILDREN'S SPECIALISTS OF SAN DIEGO - DIV OF ENDO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SEGALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-576-1700
Mailing Address - Street 1:3860 CALLE FORTUNADA
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4800
Mailing Address - Country:US
Mailing Address - Phone:858-309-6303
Mailing Address - Fax:858-309-6301
Practice Address - Street 1:8110 BIRMINGHAM WAY
Practice Address - Street 2:BUILDING 28
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2758
Practice Address - Country:US
Practice Address - Phone:858-966-4032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR006886GMedicaid
CAW13774Medicare ID - Type UnspecifiedMEDICARE GROUP PROV#