Healthcare Provider Details

I. General information

NPI: 1932403441
Provider Name (Legal Business Name): ACESSMD MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2010
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17220 NEWHOPE ST #125
FOUNTAIN VALLEY CA
92708-4272
US

IV. Provider business mailing address

PO BOX 8095
FOUNTAIN VALLEY CA
92728-8095
US

V. Phone/Fax

Practice location:
  • Phone: 714-435-0600
  • Fax:
Mailing address:
  • Phone: 949-951-9399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA47792
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG32104
License Number StateCA

VIII. Authorized Official

Name: ADEL A BOUTROS
Title or Position: PRESIDENT
Credential: MD
Phone: 714-317-3084