=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730724501
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN PAUL MICHA M D A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2019
-----------------------------------------------------
Last Update Date | 02/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 361 HOSPITAL ROAD SUITE 422
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-418-5566
-----------------------------------------------------
Fax | 949-418-5460
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 361 HOSPITAL ROAD SUITE 422
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-418-5566
-----------------------------------------------------
Fax | 949-418-5460
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MICHELLE MARIE AYLWARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-416-0888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VX0201X
-----------------------------------------------------
Taxonomy Name | Gynecologic Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------