Provider Demographics
NPI:1679702013
Name:CROSSOVER HEALTH MEDICAL GROUP
Entity type:Organization
Organization Name:CROSSOVER HEALTH MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:LYMAN
Authorized Official - Last Name:SHREEVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-235-9375
Mailing Address - Street 1:101 W. AVENIDA VISTA HERMOSA
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672
Mailing Address - Country:US
Mailing Address - Phone:949-891-0328
Mailing Address - Fax:949-272-0159
Practice Address - Street 1:26831 ALISO CREEK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-5341
Practice Address - Country:US
Practice Address - Phone:949-235-9375
Practice Address - Fax:877-497-5272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-07
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74386261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care