Healthcare Provider Details

I. General information

NPI: 1568645653
Provider Name (Legal Business Name): SUPERIOR FAMILY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 04/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 SUPERIOR AVE 1
NEWPORT BEACH CA
92663-2723
US

IV. Provider business mailing address

1419 SUPERIOR AVE 1
NEWPORT BEACH CA
92663-2723
US

V. Phone/Fax

Practice location:
  • Phone: 949-650-0587
  • Fax: 949-631-8155
Mailing address:
  • Phone: 949-650-0587
  • Fax: 949-631-8155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. RAFAEL RAFAEL PENUNURI
Title or Position: PRESIDENT
Credential: MD
Phone: 949-650-0587