Healthcare Provider Details

I. General information

NPI: 1245019454
Provider Name (Legal Business Name): LIPOV MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15785 LAGUNA CANYON RD STE 125
IRVINE CA
92618-3140
US

IV. Provider business mailing address

15785 LAGUNA CANYON RD STE 125
IRVINE CA
92618-3140
US

V. Phone/Fax

Practice location:
  • Phone: 937-838-0568
  • Fax:
Mailing address:
  • Phone: 937-838-0568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL GERSHENZON
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 937-838-0568