1750369708 NPI number — MISSION INTERNAL 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 1750369708 NPI number — MISSION INTERNAL MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSION INTERNAL 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:
1750369708
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
02/06/2007
NPI Reactivation Date:
10/05/2007

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26522 LA ALAMEDA
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
MISSION VIEJO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92691-6330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-282-1671
Provider Business Mailing Address Fax Number:
949-367-0518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27871 MEDICAL CENTER RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MISSION VIEJO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92691-6404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-347-8314
Provider Business Practice Location Address Fax Number:
949-364-5427
Provider Enumeration Date:
01/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOLIN
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
949-282-1617

Provider Taxonomy Codes

  • Taxonomy code: 261QE0800X , with the licence number:  060000510 , 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)

  • Identifier: SUR01415F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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