Provider Demographics
NPI:1457427668
Name:CASSIDY MEDICAL GROUP - CSB
Entity type:Organization
Organization Name:CASSIDY MEDICAL GROUP - CSB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-630-5487
Mailing Address - Street 1:2562 STATE ST STE D
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1663
Mailing Address - Country:US
Mailing Address - Phone:760-729-7186
Mailing Address - Fax:760-729-2753
Practice Address - Street 1:2562 STATE ST STE D
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1663
Practice Address - Country:US
Practice Address - Phone:760-729-7186
Practice Address - Fax:760-729-2753
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CASSIDY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-28
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3023OtherNEIC SITE ID, NSF BA0-7
CAGR0060603Medicaid
CA3023OtherNEIC SITE ID, NSF BA0-7
CAW14833DMedicare PIN