Basic Information
| Provider Information | |||||||||
| NPI: | 1184655797 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMISUB IRVINE MEDICAL CENTER), INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IRVINE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE 57547 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900740001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263004122 | ||||||||
| FaxNumber: | 9497532131 | ||||||||
| Practice Location | |||||||||
| Address1: | 16200 SAND CANYON AVE | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926183714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497532000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | ARMIN | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF GOVT PROGRAMS, TENET | ||||||||
| AuthorizedOfficialTelephone: | 8184362267 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 060000275 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 8376 | 01 | HEALTH NET | OTHER | HSP40693F | 05 | CA | MEDICAID | 004834-0001 | 01 | PACIFICARE OF CALIFORNIA | OTHER | 295398770 | 01 | AETNA US HEALTHCARE (NATI | OTHER | ZZZA3025Z | 01 | BS OF CALIFORNIA | OTHER | 55-5531 | 01 | BC OF CALIFORNIA | OTHER | HSP30693F | 05 | CA | MEDICAID | 000417 | 01 | HUMANA | OTHER | 050693B000000 | 01 | SECTION 1011 | OTHER |