MEDICARE: PACIFIC NEURO DIAGNOSTIC MEDICAL GROUP, INC.

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	103T00000X	Psychologist
2	111N00000X	Chiropractor
3	204D00000X	Neuromusculoskeletal Medicine & OMM Physician
4	207R00000X	Internal Medicine Physician
5	207T00000X	Neurological Surgery Physician
6	208100000X	Physical Medicine & Rehabilitation Physician
7	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician
8	207X00000X	Orthopaedic Surgery Physician	G15295	CA

General Provider Information

NPI Number	:	1497955280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC NEURO DIAGNOSTIC MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	6800 LINCOLN AVE
Second Line	:	SUITE 200
City	:	BUENA PARK
State	:	CA
Zip	:	90620-4162
Country	:	US
Telephone Number	:	714-995-5400
Fax Number	:	714-995-5254

Provider Business Practice Location Address
First Line	:	165 W HOSPITALITY LN
Second Line	:	SUITE 28
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3334
Country	:	US
Telephone Number	:	909-890-0046
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SIM C. HOFFMAN
Credential	:	MD
Telephone Number	:	714-995-5400

Provider Enumeration Date	:	07/20/2007
Last Update Date	:	10/27/2007

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