Provider Demographics
NPI:1740213198
Name:IRRADIANCE MEDICAL GROUP INC
Entity type:Organization
Organization Name:IRRADIANCE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:TSUNG LUNG
Authorized Official - Last Name:HO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-687-3214
Mailing Address - Street 1:420 E 3RD ST STE 805
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1646
Mailing Address - Country:US
Mailing Address - Phone:213-687-3214
Mailing Address - Fax:213-687-0622
Practice Address - Street 1:420 E 3RD ST STE 805
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1646
Practice Address - Country:US
Practice Address - Phone:213-687-3214
Practice Address - Fax:213-687-0622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77152207NS0135X
CAA55242207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G771521Medicaid
CAW15456Medicare ID - Type UnspecifiedGROUP NUMBER
CAWG77152CMedicare ID - Type Unspecified
CAWA55242CMedicare ID - Type Unspecified
CA00G771521Medicaid
CAG42567Medicare UPIN