Provider Demographics
NPI:1962688390
Name:SAND CANYON MEDICAL GROUP
Entity Type:Organization
Organization Name:SAND CANYON MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLARKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-417-0272
Mailing Address - Street 1:PO BOX 96365
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73143-6365
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16100 SAND CANYON AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3716
Practice Address - Country:US
Practice Address - Phone:949-417-0272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW22621Medicare PIN