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General NPI Number Information
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NPI Number | 1548735202
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Entity Type | Organization
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Legal Business Name | PROGENY PSYCHIATRIC CLINIC A MEDICAL CORPORATION
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Dates
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Enumeration Date | 10/09/2018
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Last Update Date | 08/08/2019
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Provider Practice Location Address
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Address Line | 17782 COWAN STE A
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City | IRVINE
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State | CA
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Zip | 92614-6041
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Country | US
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Telephone | 949-722-7118
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Fax | 949-396-0965
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Provider Business Mailing Address
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Address Line | 17782 COWAN STE A
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City | IRVINE
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State | CA
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Zip | 92614-6041
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Country | US
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Telephone | 949-722-7118
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Fax | 949-396-0965
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Authorized Official
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Title or Position | CEO
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Name | JASON P KELLOGG
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Credential | MD
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Telephone | 949-722-7118
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine 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 | 2084N0400X
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Taxonomy Name | Neurology Physician
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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