Provider Demographics
NPI:1346331725
Name:PALOMA MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PALOMA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:ROVZAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-443-4303
Mailing Address - Street 1:PO BOX 7087
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-7087
Mailing Address - Country:US
Mailing Address - Phone:714-571-5000
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:30230 RANCHO VIEJO RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1557
Practice Address - Country:US
Practice Address - Phone:949-443-4303
Practice Address - Fax:949-443-4033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2012-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53398174400000X
CAG54979174400000X
CA20A7942174400000X
CAA74701174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20620Medicare PIN