Provider Demographics
NPI:1528152105
Name:INTERNAL MEDI CINE ASSOCIATES MEDICAL GROUP OF SAN DIEGO, INC
Entity type:Organization
Organization Name:INTERNAL MEDI CINE ASSOCIATES MEDICAL GROUP OF SAN DIEGO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:FREDRICK
Authorized Official - Last Name:SPECKART
Authorized Official - Suffix:
Authorized Official - Credentials:MD,MFACP
Authorized Official - Phone:619-297-3737
Mailing Address - Street 1:3260 THIRD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:619-297-3737
Mailing Address - Fax:619-297-0443
Practice Address - Street 1:3260 THIRD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-297-3737
Practice Address - Fax:619-297-0443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC31776207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID
CA=========OtherTAX ID