Provider Demographics
NPI:1467478008
Name:NEWPORT CENTER MEDICAL GROUP
Entity type:Organization
Organization Name:NEWPORT CENTER MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:TILSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-720-4920
Mailing Address - Street 1:400 NEWPORT CENTER DR
Mailing Address - Street 2:SUITE 504
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7601
Mailing Address - Country:US
Mailing Address - Phone:949-720-4920
Mailing Address - Fax:949-720-4928
Practice Address - Street 1:400 NEWPORT CENTER DR
Practice Address - Street 2:SUITE 504
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7601
Practice Address - Country:US
Practice Address - Phone:949-720-4920
Practice Address - Fax:949-720-4928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11857Medicare ID - Type Unspecified