1295727261 NPI number — BREAST SPECIALISTS MEDICAL GROUP, INC.

Table of content: (NPI 1295727261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295727261 NPI number — BREAST SPECIALISTS MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREAST SPECIALISTS 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:
1295727261
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5931
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92863-5931
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-571-5000
Provider Business Mailing Address Fax Number:
714-571-5055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24401 CALLE DE LA LOUISA
Provider Second Line Business Practice Location Address:
STE. 200
Provider Business Practice Location Address City Name:
LAGUNA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92653-3623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-452-7200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MARKLE
Authorized Official First Name:
LAURALYN
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
949-452-7200

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CJ2832 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: GR0103910 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ01822Z . This is a "BLUE SHIELD OF CA" identifier . This identifiers is of the category "OTHER".




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