Healthcare Provider Details

I. General information

NPI: 1477953511
Provider Name (Legal Business Name): NEWPORT BEACH SURGICAL AND MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 NEWPORT CENTER DR SUITE 158
NEWPORT BEACH CA
92660-6972
US

IV. Provider business mailing address

PO BOX 6765
ORANGE CA
92863-6765
US

V. Phone/Fax

Practice location:
  • Phone: 949-719-1800
  • Fax: 949-719-1810
Mailing address:
  • Phone: 714-571-5000
  • Fax: 714-571-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SIMON J. MADORSKY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 949-719-1800