Provider Demographics
NPI:1750369708
Name:MISSION INTERNAL MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:MISSION INTERNAL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:WOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-282-1617
Mailing Address - Street 1:26522 LA ALAMEDA
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6330
Mailing Address - Country:US
Mailing Address - Phone:949-282-1671
Mailing Address - Fax:949-367-0518
Practice Address - Street 1:27871 MEDICAL CENTER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6404
Practice Address - Country:US
Practice Address - Phone:949-347-8314
Practice Address - Fax:949-364-5427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2010-05-24
Deactivation Date:2007-02-06
Deactivation Code:
Reactivation Date:2007-10-05
Provider Licenses
StateLicense IDTaxonomies
CA060000510261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01415FMedicaid
CASUR01415FMedicaid