Basic Information
| Provider Information | |||||||||
| NPI: | 1245514595 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SIDUS MEDICAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | YORBA LINDA MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1041 E YORBA LINDA BLVD | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | PLACENTIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928703728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145779500 | ||||||||
| FaxNumber: | 7145779504 | ||||||||
| Practice Location | |||||||||
| Address1: | 1041 E YORBA LINDA BLVD | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | PLACENTIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928703728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145779500 | ||||||||
| FaxNumber: | 7145779504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2011 | ||||||||
| LastUpdateDate: | 10/05/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KURTZ | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | MATTHEW | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7145779500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20A11054 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.