MEDICARE: REGENTS OF THE UNVIERSITY OF CALIFONRIA - UCSD MEDICAL GROUP

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy
1	103G00000X	Clinical Neuropsychologist
2	103TB0200X	Cognitive & Behavioral Psychologist
3	103TC0700X	Clinical Psychologist
4	103TC2200X	Clinical Child & Adolescent Psychologist
5	103T00000X	Psychologist

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
6	CQ4024	OTHER		RAILROAD MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ73229Z	OTHER	CA	BLUE SHIELD
2	364823303	OTHER		US DEPT OF LABOR
3	364823300	OTHER		US DEPT OF LABOR
4	364823304	OTHER		US DEPT OF LABOR
5	364823308	OTHER		US DEPT OF LABOR
7	364823305	OTHER		US DEPT OF LABOR
8	364823310	OTHER		US DEPT OF LABOR
9	CGP016905	OTHER	CA	GHPP
10	364823301	OTHER		US DEPT OF LABOR
11	364823307	OTHER		US DEPT OF LABOR
12	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
13	364823302	OTHER		US DEPT OF LABOR
14	364823306	OTHER		US DEPT OF LABOR
15	ZZZP3711Z	OTHER	CA	BLUE SHIELD

NPI Number	:	1417059874
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGENTS OF THE UNVIERSITY OF CALIFONRIA - UCSD MEDICAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 232410
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92193-2410
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 W ARBOR DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-9000
Country	:	US
Telephone Number	:	800-926-8273
Fax Number	:	888-539-8781

Authorized Official
Title or Position	:	DIRECTOR,REVENUE CYCLE & OPERATIONS
Name	:	MR. MICHAEL DENNIS PRICE
Credential	:
Telephone Number	:	858-249-6752

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	02/09/2022

211 CALLE MORSE
ARROYO, PR
00714-2350

Practice Phone: 787-839-3980
Practice Fax: 787-271-2515