Provider Demographics
NPI:1922015072
Name:HARBOR PEDIATRIC MEDICAL GROUP
Entity Type:Organization
Organization Name:HARBOR PEDIATRIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MICHELIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-645-4670
Mailing Address - Street 1:601 DOVER DR STE 7
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-5721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 DOVER DR STE 7
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-5721
Practice Address - Country:US
Practice Address - Phone:949-465-4670
Practice Address - Fax:949-722-6866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
CA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty