Provider Demographics
NPI:1801980446
Name:SAN DIEGO CARDIAC CENTER MEDICAL GROUP INC
Entity type:Organization
Organization Name:SAN DIEGO CARDIAC CENTER MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:HAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-244-6870
Mailing Address - Street 1:3131 BERGER AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4233
Mailing Address - Country:US
Mailing Address - Phone:858-244-6800
Mailing Address - Fax:858-244-6892
Practice Address - Street 1:3131 BERGER AVE
Practice Address - Street 2:STE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4233
Practice Address - Country:US
Practice Address - Phone:858-244-6800
Practice Address - Fax:858-244-6892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB1987012812207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0021760Medicaid
CAW7960Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER