Healthcare Provider Details

I. General information

NPI: 1801192497
Provider Name (Legal Business Name): SOUTH BAY GERIATRIC AND INTERNAL MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 4TH AVE #9
CHULA VISTA CA
91910-3813
US

IV. Provider business mailing address

PO BOX 92191
SAN DIEGO CA
92191-0723
US

V. Phone/Fax

Practice location:
  • Phone: 619-426-9731
  • Fax: 619-426-9733
Mailing address:
  • Phone: 619-426-9731
  • Fax: 619-426-9733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberA72963
License Number StateCA

VIII. Authorized Official

Name: MR. MUSHRIK KAISEY
Title or Position: PRESIDENT
Credential: MD
Phone: 619-426-9731