Healthcare Provider Details

I. General information

NPI: 1407860844
Provider Name (Legal Business Name): SOUTH ORANGE COUNTY SURGICAL MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24411 HEALTH CENTER DR SUITE 350
LAGUNA HILLS CA
92653-3651
US

IV. Provider business mailing address

24411 HEALTH CENTER DR STE 350
LAGUNA HILLS CA
92653-3687
US

V. Phone/Fax

Practice location:
  • Phone: 949-457-7900
  • Fax: 949-583-9148
Mailing address:
  • Phone: 949-457-7900
  • Fax: 949-583-9148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM CAMPBELL WALLACE
Title or Position: CEO
Credential: MD
Phone: 949-457-7900