Healthcare Provider Details

I. General information

NPI: 1356716013
Provider Name (Legal Business Name): INTENSIVE CARE MEDICAL SPECIALISTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2015
Last Update Date: 12/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2975 SYCAMORE DR
SIMI VALLEY CA
93065-1201
US

IV. Provider business mailing address

PO BOX 77790
CORONA CA
92877-0126
US

V. Phone/Fax

Practice location:
  • Phone: 951-278-5590
  • Fax: 951-272-9924
Mailing address:
  • Phone: 951-278-5590
  • Fax: 951-272-9924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DUC VAN NGUYEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 951-278-5590