Healthcare Provider Details

I. General information

NPI: 1245284843
Provider Name (Legal Business Name): PACIFIC COAST CARDIOLOGY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 W COAST HWY SUITE A
NEWPORT BEACH CA
92663-4007
US

IV. Provider business mailing address

PO BOX 6593
ORANGE CA
92863-6593
US

V. Phone/Fax

Practice location:
  • Phone: 949-642-5513
  • Fax: 949-646-8223
Mailing address:
  • Phone: 714-571-5000
  • Fax: 714-571-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. EMANUEL SHAOULIAN
Title or Position: PARTNER
Credential: M.D.
Phone: 949-642-5513