Basic Information
| Provider Information | |||||||||
| NPI: | 1164517843 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SADDLEBACK RESPIRATORY MEDICAL GRP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7630 | ||||||||
| Address2: | |||||||||
| City: | LAGUNA NIGUEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926077630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496433345 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24451 HEALTH CENTER DR | ||||||||
| Address2: | |||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926533689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9498374500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 03/31/2016 | ||||||||
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| AuthorizedOfficialLastName: | MCNICOL | ||||||||
| AuthorizedOfficialFirstName: | LELIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9496433345 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 00G256840 | 01 | BLUE SHIELD | OTHER | 00G256840 | 01 | BLUE CROSS | OTHER | 00G256840 | 05 | CA | MEDICAID | ZZZ53020Y | 01 | CA | BLUE CROSS/BLUE SHIELD | OTHER |