=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346437258
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IGOR JERCINOVICH, M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2007
-----------------------------------------------------
Last Update Date | 04/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 521 E ELDER ST STE 105
-----------------------------------------------------
City | FALLBROOK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92028-3082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-728-5851
-----------------------------------------------------
Fax | 760-728-0703
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 521 E ELDER ST STE 105
-----------------------------------------------------
City | FALLBROOK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92028-3082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-728-5851
-----------------------------------------------------
Fax | 760-728-0703
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | IGOR A JERCINOVICH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 760-728-5851
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------