Provider Demographics
NPI:1245284843
Name:PACIFIC COAST CARDIOLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:PACIFIC COAST CARDIOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAOULIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-642-5513
Mailing Address - Street 1:PO BOX 6593
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-6593
Mailing Address - Country:US
Mailing Address - Phone:714-571-5000
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:3300 W COAST HWY
Practice Address - Street 2:SUITE A
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4007
Practice Address - Country:US
Practice Address - Phone:949-642-5513
Practice Address - Fax:949-646-8223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083981Medicaid
CI1510OtherRAILROAD MEDICARE
CAGR0083980Medicaid
ZZZ02968ZOtherBLUE SHIELD OF CA
ZZZ56952ZOtherBLUE SHIELD OF CA
CAGR0083981Medicaid