Provider Demographics
NPI:1326228057
Name:UC IRVINE
Entity Type:Organization
Organization Name:UC IRVINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GME DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-456-7252
Mailing Address - Street 1:11 MOON DUST
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92603-3773
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:BLDG 53, ROOM 302A
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-8381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92819261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center