Provider Demographics
NPI:1104264902
Name:CROSSOVER HEALTH MEDICAL GROUP
Entity type:Organization
Organization Name:CROSSOVER HEALTH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-891-0328
Mailing Address - Street 1:26831 ALISO CREEK RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-5341
Mailing Address - Country:US
Mailing Address - Phone:949-891-0328
Mailing Address - Fax:
Practice Address - Street 1:4 STANLEY TUCKER DR
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-4039
Practice Address - Country:US
Practice Address - Phone:949-891-0328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73842174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty