Healthcare Provider Details

I. General information

NPI: 1356328470
Provider Name (Legal Business Name): ANAHEIM HILLS MEDICAL GROUP, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S ANAHEIM HILLS RD SUITE 242
ANAHEIM HILLS CA
92807-4780
US

IV. Provider business mailing address

500 S ANAHEIM HILLS RD SUITE 242
ANAHEIM HILLS CA
92807-4780
US

V. Phone/Fax

Practice location:
  • Phone: 714-974-0611
  • Fax: 714-279-9183
Mailing address:
  • Phone: 714-974-0611
  • Fax: 714-279-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A7047
License Number StateCA

VIII. Authorized Official

Name: MR. JASON CHRISTOPHER BERRY
Title or Position: PRESIDENT
Credential: D.O.
Phone: 714-974-0611