Provider Demographics
NPI:1043433220
Name:AMVI MEDICAL GROUP
Entity Type:Organization
Organization Name:AMVI MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CO
Authorized Official - Middle Name:DL
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-796-5900
Mailing Address - Street 1:1920 E. 17TH STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705
Mailing Address - Country:US
Mailing Address - Phone:714-796-5900
Mailing Address - Fax:714-560-7655
Practice Address - Street 1:1920 E. 17TH STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705
Practice Address - Country:US
Practice Address - Phone:714-796-5900
Practice Address - Fax:714-560-7655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA340910302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization