1639264278 NPI number — ORANGE COUNTY FIRST MEDICAL GROUP A PROFESSIONAL CORPORATION

Table of content: (NPI 1639264278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639264278 NPI number — ORANGE COUNTY FIRST MEDICAL GROUP A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORANGE COUNTY FIRST MEDICAL GROUP A PROFESSIONAL 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:
ANAHEIM ORANGE COUNTY FIRST MEDICAL GROUP
Provider Other Organization Name Type Code:
5
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:
1639264278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1771 W. ROMNEYA DR.
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
ANAHEIM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92801-1817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-520-3000
Provider Business Mailing Address Fax Number:
714-520-5742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1771 W. ROMNEYA DR.
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
ANAHEIM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92801-1817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-520-3000
Provider Business Practice Location Address Fax Number:
714-520-5742
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GADDAM
Authorized Official First Name:
SYAM
Authorized Official Middle Name:
PRASAD
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
714-636-9100

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; 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: "Y" .

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

  • Identifier: GR0095540 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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