Basic Information
| Provider Information | |||||||||
| NPI: | 1750369708 | ||||||||
| 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: | 9492821671 | ||||||||
| FaxNumber: | 9493670518 | ||||||||
| Practice Location | |||||||||
| Address1: | 27871 MEDICAL CENTER RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493478314 | ||||||||
| FaxNumber: | 9493645427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 05/24/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/06/2007 | ||||||||
| NPIReactivationDate: | 10/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | WOLIN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9492821617 | ||||||||
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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 | 261QE0800X | 060000510 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | SUR01415F | 05 | CA | MEDICAID |