MEDICARE: SAN DIEGO SPORTS MEDICINE & ORTHOPAEDIC CENTER INC.

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	207X00000X	Orthopaedic Surgery Physician

General Provider Information

NPI Number	:	1356869119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN DIEGO SPORTS MEDICINE & ORTHOPAEDIC CENTER INC.

Provider Business Mailing Address
First Line	:	6719 ALVARADO RD STE 200
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5256
Country	:	US
Telephone Number	:	619-229-3932
Fax Number	:	619-582-2860

Provider Business Practice Location Address
First Line	:	6719 ALVARADO RD STE 200
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5256
Country	:	US
Telephone Number	:	619-229-3932
Fax Number	:	619-582-2860

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MISS LISA MARIE SULLIVAN
Credential	:
Telephone Number	:	619-229-3932

Provider Enumeration Date	:	08/31/2017
Last Update Date	:	09/09/2019

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