=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043437379
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOS ALAMITOS COLORECTAL SURGICAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 01/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10931 CHERRY ST SUITE 200
-----------------------------------------------------
City | LOS ALAMITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90720-2445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-596-7700
-----------------------------------------------------
Fax | 562-596-7600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10931 CHERRY ST SUITE 200
-----------------------------------------------------
City | LOS ALAMITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90720-2445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-596-7700
-----------------------------------------------------
Fax | 562-596-7600
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | IMAD SHBEEB
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 562-596-7700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208C00000X
-----------------------------------------------------
Taxonomy Name | Colon & Rectal Surgery Physician
-----------------------------------------------------
License Number | G51618
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------