Healthcare Provider Details

I. General information

NPI: 1578652152
Provider Name (Legal Business Name): IRVINE SURGICAL MEDICAL GROUP CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15825 LAGUNA CANYON RD SUITE 100
IRVINE CA
92618-2125
US

IV. Provider business mailing address

15825 LAGUNA CANYON RD SUITE 100
IRVINE CA
92618-2125
US

V. Phone/Fax

Practice location:
  • Phone: 949-679-6700
  • Fax: 949-387-9530
Mailing address:
  • Phone: 949-679-6700
  • Fax: 949-387-9530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number550000008
License Number StateCA

VIII. Authorized Official

Name: ARDALAN BABAKNIA
Title or Position: CHIEF MEDICAL DIRECTOR AND FINANCIA
Credential: PHD,M.D.
Phone: 949-753-8844