Provider Demographics
NPI:1205167350
Name:MEMORIALCARE MEDICAL FOUNDATION
Entity type:Organization
Organization Name:MEMORIALCARE MEDICAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO/VP PHYSICIAN INTEGRATION
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SICAEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-696-3622
Mailing Address - Street 1:17360 BROOKHURST ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:877-696-3622
Mailing Address - Fax:
Practice Address - Street 1:17360 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-3720
Practice Address - Country:US
Practice Address - Phone:877-696-3622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-28
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEH336AMedicare PIN