Basic Information
| Provider Information | |||||||||
| NPI: | 1558783696 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UC IRVINE HEALTH CANCER CENTER, NEWPORT PACIFIC MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31001-1363 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911101363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144566324 | ||||||||
| FaxNumber: | 7144566273 | ||||||||
| Practice Location | |||||||||
| Address1: | 1640 NEWPORT BLVD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926273786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499992400 | ||||||||
| FaxNumber: | 9499992405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2014 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | WOON | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 7144566270 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF CALIFORNIA IRVINE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QI0500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Infusion Therapy |
ID Information
| ID | Type | State | Issuer | Description | W1930 | 01 | CA | MEDICARE ID-TYPE UNSPECIFIED | OTHER |