=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316997505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALBOA NEPHROLOGY MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2006
-----------------------------------------------------
Last Update Date | 11/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9373 HAZARD WAY STE 200
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92123-1226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-810-8000
-----------------------------------------------------
Fax | 858-268-1911
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 511275
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90051-7830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-810-0000
-----------------------------------------------------
Fax | 858-268-1911
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | SHAUN EDELSTEIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 858-810-8000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 204F00000X
-----------------------------------------------------
Taxonomy Name | Transplant Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------