MEDICARE: GROSSMONT HOSPITAL CORPORATION

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	332B00000X	Durable Medical Equipment & Medical Supplies
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)
3	333600000X	Pharmacy
4	3336H0001X	Home Infusion Therapy Pharmacy	PHY43865	CA

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
2	2114095	OTHER		PK

General Provider Information

NPI Number	:	1457330300
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROSSMONT HOSPITAL CORPORATION

Provider Business Mailing Address
First Line	:	3558 RUFFIN RD STE 100
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-2596
Country	:	US
Telephone Number	:	858-627-5600
Fax Number	:	858-627-5610

Provider Business Practice Location Address
First Line	:	3558 RUFFIN RD STE 100
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-2596
Country	:	US
Telephone Number	:	858-627-5600
Fax Number	:	858-627-5610

Authorized Official
Title or Position	:	CEO
Name	:	SCOTT EVANS
Credential	:
Telephone Number	:	619-740-4648

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	03/15/2019

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Directions to “GROSSMONT HOSPITAL CORPORATION ” Practice Location

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