Provider Demographics
NPI:1295727261
Name:BREAST SPECIALISTS MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:BREAST SPECIALISTS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURALYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-452-7200
Mailing Address - Street 1:PO BOX 5931
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5931
Mailing Address - Country:US
Mailing Address - Phone:714-571-5000
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:24401 CALLE DE LA LOUISA
Practice Address - Street 2:STE. 200
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3623
Practice Address - Country:US
Practice Address - Phone:949-452-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CJ2832OtherRAILROAD MEDICARE
CAGR0103910Medicaid
ZZZ01822ZOtherBLUE SHIELD OF CA
W15224Medicare PIN