Healthcare Provider Details

I. General information

NPI: 1700964665
Provider Name (Legal Business Name): THE PEDIATRIC SPECIALISTS MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 W BRANCH ST SUITE A
ARROYO GRANDE CA
93420-2611
US

IV. Provider business mailing address

138 W BRANCH ST SUITE A
ARROYO GRANDE CA
93420-2611
US

V. Phone/Fax

Practice location:
  • Phone: 805-481-3166
  • Fax: 805-481-8237
Mailing address:
  • Phone: 805-481-3166
  • Fax: 805-481-8237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number55326
License Number StateCA

VIII. Authorized Official

Name: DR. SUSAN H. HOFFMAN
Title or Position: OWNER
Credential: M.D.
Phone: 805-481-3166