Provider Demographics
NPI:1265500318
Name:PACIFIC COAST HEMATOLOGY ONCOLOGY MEDICAL GROUP INC
Entity type:Organization
Organization Name:PACIFIC COAST HEMATOLOGY ONCOLOGY MEDICAL GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-845-0200
Mailing Address - Street 1:9940 TALBERT AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5153
Mailing Address - Country:US
Mailing Address - Phone:714-845-0200
Mailing Address - Fax:714-845-0239
Practice Address - Street 1:9940 TALBERT AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4019
Practice Address - Country:US
Practice Address - Phone:714-845-0200
Practice Address - Fax:714-845-0239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0059571Medicaid
CAZZZ21205ZOtherBS OF CALIFORNIA
CAGR0059571Medicaid
CA=========OtherUNITED HEALTHCARE
CA========= DOtherHEALTH NET SELECT
CA========= 0073OtherCIGNA
CAZZZ21205ZOtherBS OF CALIFORNIA