Healthcare Provider Details

I. General information

NPI: 1104263953
Provider Name (Legal Business Name): CROSSOVER HEALTH MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 DORY RD
GLOUCESTER MA
01930-2236
US

IV. Provider business mailing address

26831 ALISO CREEK RD STE 200
ALISO VIEJO CA
92656-5341
US

V. Phone/Fax

Practice location:
  • Phone: 949-891-0328
  • Fax:
Mailing address:
  • Phone: 949-891-0328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA62815
License Number StateCA

VIII. Authorized Official

Name: RICHARD M PATRAGNONI
Title or Position: MEDICAL DIRECTOR
Credential: M.D
Phone: 949-891-0328