MEDICARE: SCRIPPS CLINIC 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	261QM1300X	Multi-Specialty Clinic/Center		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ54115Z	OTHER	CA	BLUE SHIELD OF CALIFORNIA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609852565
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCRIPPS CLINIC MEDICAL GROUP

Provider Business Mailing Address
First Line	:	FILE#54433
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90074-0001
Country	:	US
Telephone Number	:	858-784-5906
Fax Number	:	858-784-5922

Provider Business Practice Location Address
First Line	:	9333 GENESEE AVE
Second Line	:	SUITE 170
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-2111
Country	:	US
Telephone Number	:	858-882-8350
Fax Number	:	858-784-5922

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT B. SARNOFF
Credential	:	M.D.
Telephone Number	:	858-554-8862

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	08/22/2020

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