1689685711 NPI number — ANAHEIM UROLOGIC MEDICAL GROUP, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689685711 NPI number — ANAHEIM UROLOGIC MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANAHEIM UROLOGIC 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:
1689685711
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1211 W LA PALMA AVE
Provider Second Line Business Mailing Address:
307
Provider Business Mailing Address City Name:
ANAHEIM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92801-2815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-776-6456
Provider Business Mailing Address Fax Number:
714-776-6924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1211 W LA PALMA AVE
Provider Second Line Business Practice Location Address:
307
Provider Business Practice Location Address City Name:
ANAHEIM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92801-2815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-776-6456
Provider Business Practice Location Address Fax Number:
714-776-6924
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WINELAND
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-776-6456

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G030924 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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