Provider Demographics
NPI:1962413583
Name:MOBILE MEDICAL GROUP
Entity type:Organization
Organization Name:MOBILE MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARY
Authorized Official - Middle Name:GRESHAM
Authorized Official - Last Name:BAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-260-6300
Mailing Address - Street 1:5030 CAMINO DE LA SIESTA
Mailing Address - Street 2:STE 208
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3117
Mailing Address - Country:US
Mailing Address - Phone:619-260-6300
Mailing Address - Fax:619-260-6313
Practice Address - Street 1:5030 CAMINO DE LA SIESTA
Practice Address - Street 2:STE 208
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3117
Practice Address - Country:US
Practice Address - Phone:619-260-6300
Practice Address - Fax:619-260-6313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0089290Medicaid
CAZZZ61626ZOtherBLUE SHIELD
CAW14796Medicare ID - Type Unspecified