MEDICARE: ELLISON MEDICAL GROUP VEIN TREATMENT CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A108285	OTHER	CA	LICENSE

General Provider Information

NPI Number	:	1033614706
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLISON MEDICAL GROUP VEIN TREATMENT CENTER

Provider Business Mailing Address
First Line	:	6220 AVENIDA LOMA DE ORO
Second Line	:	#675731
City	:	RANCHO SANTA FE
State	:	CA
Zip	:	92027
Country	:	US
Telephone Number	:	858-926-7678
Fax Number	:	347-405-8161

Provider Business Practice Location Address
First Line	:	5330 CARROLL CANYON RD STE 140
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3758
Country	:	US
Telephone Number	:	858-926-7678
Fax Number	:	347-405-8161

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WILLIAM SCHOENFELD
Credential	:	MD
Telephone Number	:	858-926-7678

Provider Enumeration Date	:	03/26/2018
Last Update Date	:	06/02/2023

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