Provider Demographics
NPI:1477622587
Name:CROWN SURGERY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CROWN SURGERY MEDICAL GROUP INC
Other - Org Name:CROWN SURGERY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FETUS
Authorized Official - Middle Name:
Authorized Official - Last Name:DADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-973-7290
Mailing Address - Street 1:25470 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-4900
Mailing Address - Country:US
Mailing Address - Phone:951-973-7290
Mailing Address - Fax:951-973-7299
Practice Address - Street 1:25470 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 203
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-4900
Practice Address - Country:US
Practice Address - Phone:951-973-7290
Practice Address - Fax:951-973-7299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID NUMBER