Healthcare Provider Details

I. General information

NPI: 1780077230
Provider Name (Legal Business Name): CPMS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 EXECUTIVE DR STE 210
SAN DIEGO CA
92121-3023
US

IV. Provider business mailing address

PO BOX 501724
SAN DIEGO CA
92150-1724
US

V. Phone/Fax

Practice location:
  • Phone: 858-453-7700
  • Fax: 858-798-1225
Mailing address:
  • Phone: 858-453-7700
  • Fax: 858-798-1225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA86646
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA103353
License Number StateCA

VIII. Authorized Official

Name: MS. NICCI JAYNE PARKER
Title or Position: OFFICE MANAGER
Credential:
Phone: 858-453-7700