1689633125 NPI number — TUSTIN IRVINE INTERNAL MEDICINE GROUP INC.

Table of content: (NPI 1689633125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689633125 NPI number — TUSTIN IRVINE INTERNAL MEDICINE GROUP INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TUSTIN IRVINE INTERNAL MEDICINE 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:
1689633125
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17400 IRVINE BLVD
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
TUSTIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92780-3030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-838-5610
Provider Business Mailing Address Fax Number:
714-838-5931

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17400 IRVINE BLVD
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
TUSTIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92780-3030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-838-5610
Provider Business Practice Location Address Fax Number:
714-838-5931
Provider Enumeration Date:
03/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FICAROLA
Authorized Official First Name:
MARIO
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-838-5610

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: YYY 42455 Y . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1962544494 . This is a "NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: YYY 42455 Y , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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