Provider Demographics
NPI:1215196100
Name:JAMES R WENDT M D A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:JAMES R WENDT M D A PROFESSIONAL CORP
Other - Org Name:JAMES R WENDT M D A PROFESSIONAL CORP
Other - Org Type:Other Name
Authorized Official - Title/Position:FINANCIAL REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:GERI
Authorized Official - Middle Name:NMI
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-497-0286
Mailing Address - Street 1:351 HOSPITAL RD
Mailing Address - Street 2:SUITE 601
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3509
Mailing Address - Country:US
Mailing Address - Phone:949-650-3638
Mailing Address - Fax:949-650-3606
Practice Address - Street 1:351 HOSPITAL RD
Practice Address - Street 2:SUITE 601
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3509
Practice Address - Country:US
Practice Address - Phone:949-650-3638
Practice Address - Fax:949-650-3606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG53162Medicare PIN
CAA93197Medicare UPIN