Healthcare Provider Details

I. General information

NPI: 1174572788
Provider Name (Legal Business Name): PIMG; A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 07/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1236 MAIN ST
RAMONA CA
92065-2125
US

IV. Provider business mailing address

PO BOX 28199
SAN DIEGO CA
92198-0199
US

V. Phone/Fax

Practice location:
  • Phone: 760-789-5160
  • Fax:
Mailing address:
  • Phone: 858-613-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STUART NATHAN GRAHAM
Title or Position: PRESIDENT OF BOARD
Credential: MD
Phone: 858-613-8900