MEDICARE: KEARNY MESA MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417075383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEARNY MESA MEDICAL GROUP

Provider Business Mailing Address
First Line	:	7525 LINDA VISTA RD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-5301
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7525 LINDA VISTA RD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-5301
Country	:	US
Telephone Number	:	858-277-2361
Fax Number	:

Authorized Official
Title or Position	:	ADMIN.
Name	:	NOELLE BLAKELY
Credential	:
Telephone Number	:	858-277-2361

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	08/22/2020

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