Provider Demographics
NPI:1992724959
Name:EDINGER MEDICAL GROUP INC
Entity type:Organization
Organization Name:EDINGER MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBYLUZ
Authorized Official - Middle Name:
Authorized Official - Last Name:KEENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-965-2543
Mailing Address - Street 1:PO BOX 8039
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92728-8039
Mailing Address - Country:US
Mailing Address - Phone:714-965-2500
Mailing Address - Fax:714-965-2581
Practice Address - Street 1:9900 TALBERT AVE STE 301&302
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-5153
Practice Address - Country:US
Practice Address - Phone:714-965-2500
Practice Address - Fax:714-965-2583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W1466Medicare ID - Type Unspecified
W1466AMedicare ID - Type Unspecified