Provider Demographics
NPI:1407860844
Name:SOUTH ORANGE COUNTY SURGICAL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SOUTH ORANGE COUNTY SURGICAL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CAMPBELL
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-457-7900
Mailing Address - Street 1:24411 HEALTH CENTER DR
Mailing Address - Street 2:SUITE 350
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3651
Mailing Address - Country:US
Mailing Address - Phone:949-457-7900
Mailing Address - Fax:949-583-9148
Practice Address - Street 1:24411 HEALTH CENTER DR
Practice Address - Street 2:SUITE 350
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3651
Practice Address - Country:US
Practice Address - Phone:949-457-7900
Practice Address - Fax:949-583-9148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1079OtherMEDICARE PTAN