MEDICARE: FV PHYSICAL MEDICINE

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	207LP2900X	Pain Medicine (Anesthesiology) Physician	G075155	CA

General Provider Information

NPI Number	:	1811278260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FV PHYSICAL MEDICINE

Provider Business Mailing Address
First Line	:	10990 WARNER AVENUE SUITE E
Second Line	:
City	:	FOUNTAIN VALLEY
State	:	CA
Zip	:	92708
Country	:	US
Telephone Number	:	714-965-5146
Fax Number	:	714-965-5148

Provider Business Practice Location Address
First Line	:	10990 WARNER AVE STE E
Second Line	:
City	:	FOUNTAIN VALLEY
State	:	CA
Zip	:	92708-3849
Country	:	US
Telephone Number	:	714-965-0306
Fax Number	:	714-965-5148

Authorized Official
Title or Position	:	SHAREHOLDER
Name	:	DR. STEPHEN DUNDAS
Credential	:
Telephone Number	:	714-965-5146

Provider Enumeration Date	:	08/30/2011
Last Update Date	:	08/30/2011

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