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General NPI Number Information
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NPI Number | 1194450023
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Entity Type | Organization
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Legal Business Name | AGEREVERSALMD.COM A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 07/24/2022
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Last Update Date | 07/24/2022
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Provider Practice Location Address
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Address Line | 3252 HOLIDAY CT STE 211
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City | LA JOLLA
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State | CA
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Zip | 92037-0027
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Country | US
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Telephone | 858-776-0544
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Fax | 760-692-4411
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Provider Business Mailing Address
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Address Line | 444 N EL CAMINO REAL SPC 123
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City | ENCINITAS
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State | CA
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Zip | 92024-1317
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Country | US
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Telephone | 858-776-0544
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Fax | 760-692-4411
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Authorized Official
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Title or Position | CEO
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Name | PHILLIP MARK MILGRAM
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Credential | MD
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Telephone | 858-776-0544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number |
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License Number State |
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