Healthcare Provider Details

I. General information

NPI: 1639560881
Provider Name (Legal Business Name): UC IRVINE HEALTH PACIFIC COAST NEUROSURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 NEWPORT BLVD SUITE 240
COSTA MESA CA
92627-3786
US

IV. Provider business mailing address

PO BOX 54840
LOS ANGELES CA
90054-0840
US

V. Phone/Fax

Practice location:
  • Phone: 949-999-2411
  • Fax: 949-999-2408
Mailing address:
  • Phone: 714-456-3856
  • Fax: 714-456-8101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROGER L CRUMLEY
Title or Position: INTERIM PRESIDENT
Credential: MD
Phone: 714-456-2976