1518908847 NPI number — NEWPORT COAST RADIATION ONCOLOGY MEDICAL GROUP, INC

Table of content: (NPI 1518908847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518908847 NPI number — NEWPORT COAST RADIATION ONCOLOGY MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEWPORT COAST RADIATION ONCOLOGY 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:
1518908847
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT LA 21562
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91185-1562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-263-8620
Provider Business Mailing Address Fax Number:
949-263-0473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE HOAG DRIVE
Provider Second Line Business Practice Location Address:
CANCER CENTER
Provider Business Practice Location Address City Name:
NEWPORT BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92663-4162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-764-5528
Provider Business Practice Location Address Fax Number:
949-764-8106
Provider Enumeration Date:
06/09/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HAFER
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
949-764-5528

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  G53677 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: A70756 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0203X , with the licence number: G28037 , 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: ZZZ60882Z . This is a "BLUE SHIELD OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0087510 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".