=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649880147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC OFFICE ANESTHESIA SPECIALISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2020
-----------------------------------------------------
Last Update Date | 08/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12625 HIGH BLUFF DR STE 301
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-254-0512
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13990 MERCADO DR
-----------------------------------------------------
City | DEL MAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92014-3124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-254-0512
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | DR. SCOTT GILLIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 858-254-0512
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP3000X
-----------------------------------------------------
Taxonomy Name | Pediatric Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------