Basic Information
| Provider Information | |||||||||
| NPI: | 1649443169 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSION INTERNAL MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26522 LA ALAMEDA | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492821600 | ||||||||
| FaxNumber: | 9493670518 | ||||||||
| Practice Location | |||||||||
| Address1: | 27882 FORBES RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | LAGUNA NIGUEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926771267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493642955 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2008 | ||||||||
| LastUpdateDate: | 01/04/2012 | ||||||||
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| AuthorizedOfficialLastName: | WOLIN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9492821600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.