=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952625485
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMBROSE HEALTH P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2010
-----------------------------------------------------
Last Update Date | 03/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15622 JUBE WRIGHT CT
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92127-5101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-993-0857
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10531 4S COMMONS DR # 113
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92127-3517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-993-0857
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NASSER BAYATI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 619-993-0857
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | A83515
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------