Provider Demographics
NPI:1861707366
Name:THE UROLOGICAL INSTITUTE OF SAN DIEGO
Entity type:Organization
Organization Name:THE UROLOGICAL INSTITUTE OF SAN DIEGO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLER/CREDENTIALER
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-246-4281
Mailing Address - Street 1:8851 CENTER DR
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3189
Mailing Address - Country:US
Mailing Address - Phone:619-828-1000
Mailing Address - Fax:619-828-1001
Practice Address - Street 1:8851 CENTER DR
Practice Address - Street 2:SUITE 208
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3189
Practice Address - Country:US
Practice Address - Phone:619-828-1000
Practice Address - Fax:619-828-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85788208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0071060Medicaid
CAH04985Medicare PIN