=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225366610
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANNE MARIE MCNEILL, MD, PHD, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2009
-----------------------------------------------------
Last Update Date | 10/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1441 AVOCADO AVE SUITE 702
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-7721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-325-1217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1441 AVOCADO AVE SUITE 702
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-7721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-325-1217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANNE MARIE MCNEILL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 714-227-6276
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------