Healthcare Provider Details

I. General information

NPI: 1477644474
Provider Name (Legal Business Name): SCRIPPS MERCY PHYSICIANS CARDIOLOGY MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4077 FIFTH AVENUE SCRIPPS MERCY HOSPITAL
SAN DIEGO CA
92103
US

IV. Provider business mailing address

550 WASHINGTON ST SUITE 841
SAN DIEGO CA
92103-2213
US

V. Phone/Fax

Practice location:
  • Phone: 619-359-6600
  • Fax: 619-632-5736
Mailing address:
  • Phone: 619-359-6600
  • Fax: 619-632-5736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: JERROLD GLASSMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 858-344-3411