MEDICARE: PEDIATRIC CARE 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	208000000X	Pediatrics Physician	A24153	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851337356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC CARE MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	17822 BEACH BLVD
Second Line	:	SUITE 278
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-7101
Country	:	US
Telephone Number	:	714-842-1441
Fax Number	:	714-843-0394

Provider Business Practice Location Address
First Line	:	17822 BEACH BLVD
Second Line	:	SUITE 278
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-7101
Country	:	US
Telephone Number	:	714-842-1441
Fax Number	:	714-843-0394

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PAUL Y QAQUNDAH
Credential	:	M.D.
Telephone Number	:	714-842-1441

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	08/22/2020

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