1003035882 NPI number — PERINATAL DX MEDICAL GRP OR ORANGE COUNTY

Table of content: (NPI 1003035882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003035882 NPI number — PERINATAL DX MEDICAL GRP OR ORANGE COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERINATAL DX MEDICAL GRP OR ORANGE COUNTY
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:
1003035882
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11180 WARNER AVE
Provider Second Line Business Mailing Address:
#263
Provider Business Mailing Address City Name:
FOUNTAIN VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92708-7501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-241-9742
Provider Business Mailing Address Fax Number:
714-241-0136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11180 WARNER AVE
Provider Second Line Business Practice Location Address:
#263
Provider Business Practice Location Address City Name:
FOUNTAIN VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92708-7501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-241-9742
Provider Business Practice Location Address Fax Number:
714-241-0136
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REED
Authorized Official First Name:
PAM
Authorized Official Middle Name:
R
Authorized Official Title or Position:
SONOGRAPHER
Authorized Official Telephone Number:
714-241-9742

Provider Taxonomy Codes

  • Taxonomy code: 207VH0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ95475Z . This is a "BLUE SHIELD OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0018070 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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