MEDICARE: PACIFIC SURGICAL INSTITUTE OF PAIN MANAGEMENT

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	261QA1903X	Ambulatory Surgical Clinic/Center	090000607	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	090000607	OTHER	CA	STATE OF CALIF DHS

General Provider Information

NPI Number	:	1528130879
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC SURGICAL INSTITUTE OF PAIN MANAGEMENT

Provider Business Mailing Address
First Line	:	3703 CAMINO DEL RIO SOUTH
Second Line	:	SUITE 101
City	:	SAN DIEGO
State	:	CA
Zip	:	92108
Country	:	US
Telephone Number	:	619-640-1555
Fax Number	:	619-640-9581

Provider Business Practice Location Address
First Line	:	3703 CAMINO DEL RIO SOUTH
Second Line	:	SUITE 101
City	:	SAN DIEGO
State	:	CA
Zip	:	92108
Country	:	US
Telephone Number	:	619-640-1555
Fax Number	:	619-640-9581

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. MATTHEW D RIFAT
Credential	:	ATTY
Telephone Number	:	619-282-0216

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	01/28/2016

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Directions to “PACIFIC SURGICAL INSTITUTE OF PAIN MANAGEMENT ” Practice Location

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