1104960749 NPI number — S M MULTISPECIALTY MEDICAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104960749 NPI number — S M MULTISPECIALTY MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
S M MULTISPECIALTY MEDICAL CORPORATION
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:
SUNRISE MULTI-SPECIALTY MEDICAL GROUP
Provider Other Organization Name Type Code:
3
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:
1104960749
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2492 WALNUT AVE
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
TUSTIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92780-6953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-669-1997
Provider Business Mailing Address Fax Number:
714-573-7424

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2492 WALNUT AVE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
TUSTIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92780-6953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-669-1997
Provider Business Practice Location Address Fax Number:
714-573-7424
Provider Enumeration Date:
02/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAPARA
Authorized Official First Name:
SUNIL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-970-0911

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A37744 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: 20A8503 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: A37744 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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