Provider Demographics
NPI:1447643804
Name:CROSSOVER HEALTH MEDICAL GROUP
Entity type:Organization
Organization Name:CROSSOVER HEALTH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAKIOKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-891-0328
Mailing Address - Street 1:65 ENTERPRISE
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2705
Mailing Address - Country:US
Mailing Address - Phone:949-891-0328
Mailing Address - Fax:949-272-0159
Practice Address - Street 1:806 JACKSON ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-6264
Practice Address - Country:US
Practice Address - Phone:949-891-0328
Practice Address - Fax:949-272-0159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74385208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty