Provider Demographics
NPI:1225063340
Name:CENTRAL COUNTY CHEST MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:CENTRAL COUNTY CHEST MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUIRRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-979-2825
Mailing Address - Street 1:11180 WARNER AVE STE 253
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7515
Mailing Address - Country:US
Mailing Address - Phone:714-979-2825
Mailing Address - Fax:714-979-2862
Practice Address - Street 1:11180 WARNER AVE STE 253
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7515
Practice Address - Country:US
Practice Address - Phone:714-979-2825
Practice Address - Fax:714-979-2862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42385207R00000X, 207RP1001X
207R00000X
CAA43693207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42385OtherSTATE LIC
CAGR0053330OtherCAL-OPTIMA
CAW11174OtherMEDICARE GROUP NUMBER
CAZZZ33736ZOtherBLUE SHIELD OF CALIFORNIA
CAA43693OtherSTATE LIC
CAZZZ33736ZOtherBLUE SHIELD OF CALIFORNIA
CA=========OtherBLUE CROSS OF CALIFORNIA
CAW11174OtherMEDICARE GROUP NUMBER