MEDICARE: EDEN FERTILITY CENTER OF NEWPORT BEACH

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	:	1124670674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDEN FERTILITY CENTER OF NEWPORT BEACH

Provider Business Mailing Address
First Line	:	20360 SW BIRCH ST STE 200
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-1534
Country	:	US
Telephone Number	:	949-688-1002
Fax Number	:

Provider Business Practice Location Address
First Line	:	20360 SW BIRCH ST STE 200
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-1534
Country	:	US
Telephone Number	:	949-688-1002
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	MICHAEL RUSZCZYNSKI
Credential	:
Telephone Number	:	310-927-4044

Provider Enumeration Date	:	07/15/2019
Last Update Date	:	08/26/2019

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