Provider Demographics
NPI:1972664258
Name:BASTANCHURY HEIGHTS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BASTANCHURY HEIGHTS MEDICAL GROUP, INC.
Other - Org Name:BASTANCHURY HEIGHTS MEDICAL GROUP, CENTER FOR WOMEN'S HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:THANOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-990-2900
Mailing Address - Street 1:2264 N STATE COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-1361
Mailing Address - Country:US
Mailing Address - Phone:714-255-7045
Mailing Address - Fax:714-256-4733
Practice Address - Street 1:2264 N STATE COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-1361
Practice Address - Country:US
Practice Address - Phone:714-255-7045
Practice Address - Fax:714-256-4733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0050970Medicaid
CAGR0050970Medicaid