Healthcare Provider Details

I. General information

NPI: 1316997505
Provider Name (Legal Business Name): BALBOA NEPHROLOGY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9373 HAZARD WAY STE 200
SAN DIEGO CA
92123-1226
US

IV. Provider business mailing address

PO BOX 511275
LOS ANGELES CA
90051-7830
US

V. Phone/Fax

Practice location:
  • Phone: 858-810-8000
  • Fax: 858-268-1911
Mailing address:
  • Phone: 858-810-0000
  • Fax: 858-268-1911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: SHAUN EDELSTEIN
Title or Position: CFO
Credential:
Phone: 858-810-8000