Healthcare Provider Details

I. General information

NPI: 1043433220
Provider Name (Legal Business Name): AMVI MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 E. 17TH STREET SUITE 200
SANTA ANA CA
92705
US

IV. Provider business mailing address

1920 E. 17TH STREET SUITE 200
SANTA ANA CA
92705
US

V. Phone/Fax

Practice location:
  • Phone: 714-796-5900
  • Fax: 714-560-7655
Mailing address:
  • Phone: 714-796-5900
  • Fax: 714-560-7655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberA340910
License Number StateCA

VIII. Authorized Official

Name: DR. CO D.L. PHAM
Title or Position: GROUP PRESIDENT
Credential: M.D.
Phone: 714-796-5900