Provider Demographics
NPI:1700821691
Name:PACIFIC CARDIOVASCULAR ASSOCIATES MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PACIFIC CARDIOVASCULAR ASSOCIATES MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:RUGGIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-445-0220
Mailing Address - Street 1:3080 BRISTOL ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3093
Mailing Address - Country:US
Mailing Address - Phone:714-445-0220
Mailing Address - Fax:714-445-0245
Practice Address - Street 1:3080 BRISTOL ST
Practice Address - Street 2:#600
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3093
Practice Address - Country:US
Practice Address - Phone:714-445-0220
Practice Address - Fax:714-445-0245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0063770Medicaid
CAW13321Medicare ID - Type Unspecified