Provider Demographics
NPI:1891818019
Name:IRVINE MEDICAL GROUP
Entity Type:Organization
Organization Name:IRVINE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-727-3793
Mailing Address - Street 1:16300 SAND CANYON AVE
Mailing Address - Street 2:SUITE 1009
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3711
Mailing Address - Country:US
Mailing Address - Phone:949-727-3793
Mailing Address - Fax:
Practice Address - Street 1:16300 SAND CANYON AVE
Practice Address - Street 2:SUITE 1009
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3711
Practice Address - Country:US
Practice Address - Phone:949-727-3793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32042207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11345Medicare UPIN
CAW11345Medicare ID - Type UnspecifiedMEDICARE