Provider Demographics
NPI:1376843771
Name:BRISTOL MCFADDEN MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BRISTOL MCFADDEN MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:KASIN
Authorized Official - Middle Name:EKMAHA
Authorized Official - Last Name:CHAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-966-0646
Mailing Address - Street 1:1226 E MCFADDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-4106
Mailing Address - Country:US
Mailing Address - Phone:714-245-0288
Mailing Address - Fax:714-245-0488
Practice Address - Street 1:1226 E MCFADDEN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-4106
Practice Address - Country:US
Practice Address - Phone:714-245-0288
Practice Address - Fax:714-245-0488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0009850Medicaid
CAGR0009850Medicaid