Provider Demographics
NPI:1700821915
Name:PAC NEURO INC
Entity type:Organization
Organization Name:PAC NEURO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-810-1010
Mailing Address - Street 1:3590 CAMINO DEL RIO NO.
Mailing Address - Street 2:SUITE# 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1716
Mailing Address - Country:US
Mailing Address - Phone:619-810-1010
Mailing Address - Fax:619-810-1011
Practice Address - Street 1:3590 CAMINO DEL RIO NO.
Practice Address - Street 2:SUITE# 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1716
Practice Address - Country:US
Practice Address - Phone:619-810-1010
Practice Address - Fax:619-810-1011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A625630Medicaid
CAWA62563AMedicare PIN
CA00A625630Medicaid
CA5939880001Medicare NSC