Provider Demographics
NPI:1811273345
Name:CROSSOVER HEALTH MEDICAL GROUP
Entity type:Organization
Organization Name:CROSSOVER HEALTH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:LYMAN
Authorized Official - Last Name:SHREEVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-891-0328
Mailing Address - Street 1:15 ENTERPRISE
Mailing Address - Street 2:#330
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2652
Mailing Address - Country:US
Mailing Address - Phone:949-891-0328
Mailing Address - Fax:
Practice Address - Street 1:2511 LAGUNA BLVD
Practice Address - Street 2:MS 217 - FIT
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7421
Practice Address - Country:US
Practice Address - Phone:949-891-0328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-28
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74386174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty