Basic Information
| Provider Information | |||||||||
| NPI: | 1346331725 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALOMA MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7087 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928637087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145715000 | ||||||||
| FaxNumber: | 7145715055 | ||||||||
| Practice Location | |||||||||
| Address1: | 30230 RANCHO VIEJO RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAN JUAN CAPISTRANO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926751557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494434303 | ||||||||
| FaxNumber: | 9494434033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 09/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | ROVZAR | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9494434303 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G54979 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | 20A7942 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | A74701 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | G53398 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.