Provider Demographics
NPI:1578652152
Name:IRVINE SURGICAL MEDICAL GROUP CORP
Entity type:Organization
Organization Name:IRVINE SURGICAL MEDICAL GROUP CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL DIRECTOR AND FINANCIA
Authorized Official - Prefix:
Authorized Official - First Name:ARDALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BABAKNIA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,MD
Authorized Official - Phone:949-753-8844
Mailing Address - Street 1:15825 LAGUNA CANYON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2125
Mailing Address - Country:US
Mailing Address - Phone:949-679-6700
Mailing Address - Fax:949-387-9530
Practice Address - Street 1:15825 LAGUNA CANYON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2125
Practice Address - Country:US
Practice Address - Phone:949-679-6700
Practice Address - Fax:949-387-9530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000008261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01683FMedicaid
CA550000008OtherDHS STATE LICENSE
CA05D1025785OtherCLIA
CA05-C0001683Medicare ID - Type Unspecified
CASUR01683FMedicaid