Basic Information
| Provider Information | |||||||||
| NPI: | 1962542159 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAGUNA HILLS PEDIATRIC MEDICAL GROUP, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAGUNA VIEJO PEDIATRIC MEDICAL GROUP, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24953 PASEO DE VALENCIA | ||||||||
| Address2: | #5A | ||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926534342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499511376 | ||||||||
| FaxNumber: | 9499516378 | ||||||||
| Practice Location | |||||||||
| Address1: | 24953 PASEO DE VALENCIA | ||||||||
| Address2: | #5A | ||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926534342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499511376 | ||||||||
| FaxNumber: | 9499516378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9499511376 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G320830 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.