Provider Demographics
NPI:1073874970
Name:NEURORESCUE, A PROFESSIONAL MEDICAL
Entity Type:Organization
Organization Name:NEURORESCUE, A PROFESSIONAL MEDICAL
Other - Org Name:SOUTHERN CALIFORNIA NEURORESCUE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIAN
Authorized Official - Middle Name:MOHSIN
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-443-0011
Mailing Address - Street 1:2200 COLLIER CT
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-1525
Mailing Address - Country:US
Mailing Address - Phone:714-443-0011
Mailing Address - Fax:949-284-0604
Practice Address - Street 1:18111 BROOKHURST ST
Practice Address - Street 2:5800
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6728
Practice Address - Country:US
Practice Address - Phone:714-443-0011
Practice Address - Fax:949-284-0604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66315207PE0004X, 207RC0200X, 207T00000X, 2084N0400X, 2084V0102X, 2085N0700X, 2085R0204X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular NeurologyGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty