Healthcare Provider Details

I. General information

NPI: 1568971869
Provider Name (Legal Business Name): BROAD REACH SPECIALTY SURGERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 REYNOLDS AVE STE 200
IRVINE CA
92614-5563
US

IV. Provider business mailing address

1400 REYNOLDS AVE STE 200
IRVINE CA
92614-5563
US

V. Phone/Fax

Practice location:
  • Phone: 949-387-4724
  • Fax:
Mailing address:
  • Phone: 949-387-4724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN JOSEPH HEWETT
Title or Position: PRESIDENT
Credential: MD
Phone: 949-387-4724