Provider Demographics
NPI:1245393602
Name:MARYAM RAHBAR, MD, INC.
Entity Type:Organization
Organization Name:MARYAM RAHBAR, MD, INC.
Other - Org Name:PACIFIC COAST SPINE INSTITUTE AND PAIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHBAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-847-3666
Mailing Address - Street 1:PO BOX 11869
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-5044
Mailing Address - Country:US
Mailing Address - Phone:714-847-3666
Mailing Address - Fax:714-847-7171
Practice Address - Street 1:17822 BEACH BLVD STE 101
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-7179
Practice Address - Country:US
Practice Address - Phone:714-847-3666
Practice Address - Fax:714-847-7171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAAAHC 77516261QA1903X
CAA2677838261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D1073514OtherCLIA
CAA267838OtherCITY BUSINESS LICENSE
CA77516OtherAAAHC ACCREDITATION
CAFNP36985OtherFICTITIOUS NAME PERMIT
CAPTAN/ F1872Medicare UPIN