MEDICARE: CROSSOVER HEALTH MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1083070981
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSOVER HEALTH MEDICAL GROUP

Provider Business Mailing Address
First Line	:	101 W AVENIDA VISTA HERMOSA
Second Line	:	SUITE 120
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-7706
Country	:	US
Telephone Number	:	949-891-0328
Fax Number	:

Provider Business Practice Location Address
First Line	:	2371 OWEN ST
Second Line	:
City	:	SANTA CLARA
State	:	CA
Zip	:	95054-3212
Country	:	US
Telephone Number	:	949-891-0328
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL OPERATIONS
Name	:	ANGIE SAKIOKA
Credential	:
Telephone Number	:	949-891-0328

Provider Enumeration Date	:	01/07/2016
Last Update Date	:	05/10/2017

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Directions to “CROSSOVER HEALTH MEDICAL GROUP ” Practice Location

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