Healthcare Provider Details

I. General information

NPI: 1699317644
Provider Name (Legal Business Name): AVICENNA CRITICAL CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2019
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 EL CAJON BLVD
SAN DIEGO CA
92104-1005
US

IV. Provider business mailing address

PO BOX 3363
LA JOLLA CA
92038-3363
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: AHMED SALEM
Title or Position: OWNER
Credential: D.O
Phone: 858-336-8177