Healthcare Provider Details

I. General information

NPI: 1891818019
Provider Name (Legal Business Name): IRVINE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 06/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16300 SAND CANYON AVE SUITE 1009
IRVINE CA
92618-3711
US

IV. Provider business mailing address

16300 SAND CANYON AVE SUITE 1009
IRVINE CA
92618-3711
US

V. Phone/Fax

Practice location:
  • Phone: 949-727-3793
  • Fax:
Mailing address:
  • Phone: 949-727-3793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberG32042
License Number StateCA

VIII. Authorized Official

Name: MARSHALL GROSSMAN
Title or Position: OWNER
Credential:
Phone: 949-727-3793