Provider Demographics
NPI:1447295183
Name:PREVENTIVE WOMEN'S HEALTH CARE MEDICAL GROUP, INC
Entity type:Organization
Organization Name:PREVENTIVE WOMEN'S HEALTH CARE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSALYN
Authorized Official - Middle Name:PATRICE
Authorized Official - Last Name:BAXTER-JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-277-1113
Mailing Address - Street 1:7625 MESA COLLEGE DR
Mailing Address - Street 2:101
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5343
Mailing Address - Country:US
Mailing Address - Phone:858-277-1113
Mailing Address - Fax:858-277-7639
Practice Address - Street 1:7625 MESA COLLEGE DR
Practice Address - Street 2:101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-5343
Practice Address - Country:US
Practice Address - Phone:858-277-1113
Practice Address - Fax:858-277-7639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54625207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G546250Medicaid
CA00G546250Medicaid