Provider Demographics
NPI:1649443169
Name:MISSION INTERNAL MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:MISSION INTERNAL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:WOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-282-1600
Mailing Address - Street 1:26522 LA ALAMEDA
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6330
Mailing Address - Country:US
Mailing Address - Phone:949-282-1600
Mailing Address - Fax:949-367-0518
Practice Address - Street 1:27882 FORBES RD
Practice Address - Street 2:SUITE 110
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-1267
Practice Address - Country:US
Practice Address - Phone:949-364-2955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW890Medicare PIN