Provider Demographics
NPI:1285702654
Name:SCRIPPS RANCH MEDICAL CLINIC
Entity type:Organization
Organization Name:SCRIPPS RANCH MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GEN PTR/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:WASSERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-271-6962
Mailing Address - Street 1:9999 MIRA MESA BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1006
Mailing Address - Country:US
Mailing Address - Phone:858-271-6962
Mailing Address - Fax:858-271-5327
Practice Address - Street 1:9999 MIRA MESA BLVD STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1006
Practice Address - Country:US
Practice Address - Phone:858-271-6962
Practice Address - Fax:858-271-5327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ64795ZOtherBLUE SHIELD
CAZZZ64795ZOtherBLUE SHIELD