MEDICARE: PACIFIC COAST CARDIOLOGY 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	207U00000X	Nuclear Medicine Physician
2	207RC0000X	Cardiovascular Disease Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CI1510	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	ZZZ02968Z	OTHER	BLUE SHIELD OF CA
5	ZZZ56952Z	OTHER	BLUE SHIELD OF CA

General Provider Information

NPI Number	:	1245284843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC COAST CARDIOLOGY MEDICAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 6593
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92863-6593
Country	:	US
Telephone Number	:	714-571-5000
Fax Number	:	714-571-5055

Provider Business Practice Location Address
First Line	:	3300 W COAST HWY
Second Line	:	SUITE A
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-4007
Country	:	US
Telephone Number	:	949-642-5513
Fax Number	:	949-646-8223

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. EMANUEL SHAOULIAN
Credential	:	M.D.
Telephone Number	:	949-642-5513

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	03/15/2011

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Directions to “PACIFIC COAST CARDIOLOGY MEDICAL GROUP ” Practice Location

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