Provider Demographics
NPI:1124123096
Name:MISSION CHILDREN'S MEDICAL GROUP, INC
Entity type:Organization
Organization Name:MISSION CHILDREN'S MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:D
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-364-8700
Mailing Address - Street 1:26732 CROWN VALLEY PKWY
Mailing Address - Street 2:STE 571
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6306
Mailing Address - Country:US
Mailing Address - Phone:949-364-8700
Mailing Address - Fax:949-365-1011
Practice Address - Street 1:26732 CROWN VALLEY PKWY
Practice Address - Street 2:STE 571
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6306
Practice Address - Country:US
Practice Address - Phone:949-364-8700
Practice Address - Fax:949-365-1011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15317Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER