Healthcare Provider Details

I. General information

NPI: 1447587050
Provider Name (Legal Business Name): PACIFIC SHORES MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2009
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16300 SAND CANYON AVE STE 207
IRVINE CA
92618
US

IV. Provider business mailing address

1043 ELM AVE STE 104
LONG BEACH CA
90813-3271
US

V. Phone/Fax

Practice location:
  • Phone: 949-333-7580
  • Fax: 949-333-7599
Mailing address:
  • Phone: 562-590-0345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: NERSES SIMON TCHEKMEDYAIN
Title or Position: CEO
Credential: MD
Phone: 949-333-7580