Provider Demographics
NPI:1316997505
Name:BALBOA NEPHROLOGY MEDICAL GROUP INC
Entity type:Organization
Organization Name:BALBOA NEPHROLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDELSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-810-8000
Mailing Address - Street 1:4225 EXECUTIVE SQ STE 450
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-8411
Mailing Address - Country:US
Mailing Address - Phone:858-810-0000
Mailing Address - Fax:858-268-1911
Practice Address - Street 1:4225 EXECUTIVE SQ STE 450
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-8411
Practice Address - Country:US
Practice Address - Phone:858-810-8000
Practice Address - Fax:858-268-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No204F00000XAllopathic & Osteopathic PhysiciansTransplant SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04938ZOtherMEDICARE PTAN, NO CA
CAW1487OtherMEDICARE PTAN, SO CA
CACB251966OtherMEDICARE PTAN ORANGE COUNTY