Provider Demographics
NPI:1356328470
Name:ANAHEIM HILLS MEDICAL GROUP, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ANAHEIM HILLS MEDICAL GROUP, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:714-974-0611
Mailing Address - Street 1:500 S ANAHEIM HILLS RD
Mailing Address - Street 2:SUITE 242
Mailing Address - City:ANAHEIM HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4780
Mailing Address - Country:US
Mailing Address - Phone:714-974-0611
Mailing Address - Fax:714-279-9183
Practice Address - Street 1:500 S ANAHEIM HILLS RD
Practice Address - Street 2:SUITE 242
Practice Address - City:ANAHEIM HILLS
Practice Address - State:CA
Practice Address - Zip Code:92807-4780
Practice Address - Country:US
Practice Address - Phone:714-974-0611
Practice Address - Fax:714-279-9183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG95843Medicare UPIN
CA20A7047Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER