=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407112147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY OF SAN DIEGO MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2012
-----------------------------------------------------
Last Update Date | 04/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9500 GILMAN DR SOM BUILDING #1, ROOM 103
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92093-5004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-822-5604
-----------------------------------------------------
Fax | 858-822-6994
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 249 BONAIR ST
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-5974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-249-0547
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SURGICAL RESIDENT
-----------------------------------------------------
Name | JENNIFER LYNN BAKER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 515-249-0547
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | A120237
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------