Provider Demographics
NPI:1689633125
Name:TUSTIN IRVINE INTERNAL MEDICINE GROUP INC.
Entity Type:Organization
Organization Name:TUSTIN IRVINE INTERNAL MEDICINE GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:S
Authorized Official - Last Name:FICAROLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-838-5610
Mailing Address - Street 1:17400 IRVINE BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3030
Mailing Address - Country:US
Mailing Address - Phone:714-838-5610
Mailing Address - Fax:714-838-5931
Practice Address - Street 1:17400 IRVINE BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3030
Practice Address - Country:US
Practice Address - Phone:714-838-5610
Practice Address - Fax:714-838-5931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY 42455 YOtherBLUE SHIELD
CA1962544494OtherNPI
CAYYY 42455 YMedicaid
CAA 22336Medicare UPIN
CAA 47465Medicare UPIN
CAWA61483DMedicare PIN
CAWG38399AMedicare PIN
CAWG56794AMedicare PIN
CAYYY 42455 YOtherBLUE SHIELD
CAA 39242Medicare UPIN
CAWA91056AMedicare PIN
CAE 88030Medicare UPIN
CAI 59444Medicare UPIN
CAYYY 42455 YMedicaid
CAG58721Medicare UPIN
CAW 1779Medicare PIN
CAI 13910Medicare UPIN