Provider Demographics
NPI:1629153143
Name:MISSION NEUROLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:MISSION NEUROLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LUDEMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-365-8877
Mailing Address - Street 1:27800 MEDICAL CENTER RD
Mailing Address - Street 2:SUITE 263
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6447
Mailing Address - Country:US
Mailing Address - Phone:949-365-8877
Mailing Address - Fax:949-365-8878
Practice Address - Street 1:27800 MEDICAL CENTER RD
Practice Address - Street 2:SUITE 263
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6447
Practice Address - Country:US
Practice Address - Phone:949-365-8877
Practice Address - Fax:949-365-8878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G531350Medicaid
CAA52452Medicare UPIN
CA00G531350Medicaid