Provider Demographics
NPI:1366648594
Name:BEACH OBSTETRICS & GYNECOLOGY MEDICAL GROUP A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BEACH OBSTETRICS & GYNECOLOGY MEDICAL GROUP A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:ILLECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-841-9899
Mailing Address - Street 1:19582 BEACH BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-2996
Mailing Address - Country:US
Mailing Address - Phone:714-841-9899
Mailing Address - Fax:714-841-2729
Practice Address - Street 1:19582 BEACH BLVD STE 202
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-2996
Practice Address - Country:US
Practice Address - Phone:714-841-9899
Practice Address - Fax:714-841-2729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2019-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG067729174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF11563Medicare UPIN