MEDICARE: CHILDREN'S SPECIALISTS OF SAN DIEGO - DIV OF GEN

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207SG0202X	Clinical Biochemical Genetics Physician
2	207SG0203X	Clinical Molecular Genetics Physician
3	207SG0201X	Clinical Genetics (M.D.) Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275690877
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'S SPECIALISTS OF SAN DIEGO - DIV OF GEN

Provider Business Mailing Address
First Line	:	3860 CALLE FORTUNADA
Second Line	:	SUITE 210
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4800
Country	:	US
Telephone Number	:	858-309-6303
Fax Number	:	858-309-6301

Provider Business Practice Location Address
First Line	:	8110 BIRMINGHAM WAY
Second Line	:	BUILDING 28
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-2758
Country	:	US
Telephone Number	:	858-966-5840
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HERBERT C. KIMMONS JR.
Credential	:	M.D.
Telephone Number	:	858-966-8567

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	04/22/2008

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