=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679747448
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRETT A GIDNEY MD A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2008
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5555 RESERVOIR DR SUITE 112
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92120-5134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-287-7060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5555 RESERVOIR DR SUITE 112
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92120-5134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-287-7060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT, CEO
-----------------------------------------------------
Name | DR. BRETT ANDREW GIDNEY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 619-287-7060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0001X
-----------------------------------------------------
Taxonomy Name | Clinical Cardiac Electrophysiology Physician
-----------------------------------------------------
License Number | A81336
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------