1104905199 NPI number — WESTERN PULMONARY MEDICAL GROUP INC

Table of content: (NPI 1104905199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104905199 NPI number — WESTERN PULMONARY MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN PULMONARY MEDICAL GROUP INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104905199
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19742 MACARTHUR BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92612-2408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-428-0330
Provider Business Mailing Address Fax Number:
714-879-1049

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19742 MACARTHUR BLVD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92612-2408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-428-0330
Provider Business Practice Location Address Fax Number:
714-879-1049
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PEARLE
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MD OWNER
Authorized Official Telephone Number:
714-446-8702

Provider Taxonomy Codes

  • Taxonomy code: 207RC0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ97067Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 199372700 . This is a "DEPT OF LABOR PROV NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0014371 . This is a "MEDI-CAL GRP PRV NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1982783940 . This is a "DR PEARLE NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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