MEDICARE: CASSIDY MEDICAL GROUP - CSB

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	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3023	OTHER	CA	NEIC SITE ID, NSF BA0-7
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457427668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CASSIDY MEDICAL GROUP - CSB

Provider Business Mailing Address
First Line	:	2562 STATE ST STE D
Second Line	:
City	:	CARLSBAD
State	:	CA
Zip	:	92008-1663
Country	:	US
Telephone Number	:	760-729-7186
Fax Number	:	760-729-2753

Provider Business Practice Location Address
First Line	:	2562 STATE ST STE D
Second Line	:
City	:	CARLSBAD
State	:	CA
Zip	:	92008-1663
Country	:	US
Telephone Number	:	760-729-7186
Fax Number	:	760-729-2753

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JUDITH M KRUEGER
Credential	:
Telephone Number	:	760-630-5487

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	03/14/2008

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Directions to “CASSIDY MEDICAL GROUP - CSB ” Practice Location

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