MEDICARE: SIMON MADORSKY M.D A MEDICAL CORPORATION

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	207YS0123X	Facial Plastic Surgery Physician	A50075	CA

General Provider Information

NPI Number	:	1417108556
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIMON MADORSKY M.D A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 15788
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92659-5788
Country	:	US
Telephone Number	:	949-574-4638
Fax Number	:	949-574-4680

Provider Business Practice Location Address
First Line	:	180 NEWPORT CENTER DR
Second Line	:	SUITE 158
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-6972
Country	:	US
Telephone Number	:	949-719-1800
Fax Number	:	949-719-1810

Authorized Official
Title or Position	:	SUPERVISOR BILLING SUPPORT SERVICES
Name	:	MALINDA VANCE
Credential	:
Telephone Number	:	949-574-4652

Provider Enumeration Date	:	10/07/2008
Last Update Date	:	01/31/2012

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Directions to “SIMON MADORSKY M.D A MEDICAL CORPORATION ” Practice Location

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