South Coast Outpatient Surg Ctr Balboa Surgery Center

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

Legal business name

SOUTH COAST OUTPATIENT SURG CTR BALBOA SURGERY CENTER

Practice address

1101 Bayside Dr
Suite 101
Corona del Mar, CA 92625-1702

Phone

(949) 718-6900

Fax

(949) 718-9367

NPI assigned

May 6, 2009

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Michael Wayne Niccole, M.D.

Title

Medical Director

Phone

(310) 792-3914

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• SOUTH COAST OUTPATIENT SURGERY CENTER Doing business as

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Ambulatory surgical center certification: CCN 05C0001929

Legal name

SOUTH COAST OUTPATIENT SURGERY CENTER

Certification status

Active

Provider type (POS)

Ambulatory surgical center

Participating since

May 26, 2010

Last certification

Apr 29, 2019

Ownership / control type

Proprietary

Facility address

1101 Bayside Drive, Suite 101
Corona del Mar, CA 92625

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1241568000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1540857600000",
    "number": "1053545905",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1101 BAYSIDE DR STE 100",
            "city": "CORONA DEL MAR",
            "state": "CA",
            "postal_code": "926251754",
            "telephone_number": "949-718-6900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1101 BAYSIDE DR",
            "address_2": "SUITE 101",
            "city": "CORONA DEL MAR",
            "state": "CA",
            "postal_code": "926251702",
            "telephone_number": "949-718-6900",
            "fax_number": "949-718-9367"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH COAST OUTPATIENT SURG CTR BALBOA SURGERY CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-05-06",
        "last_updated": "2018-10-30",
        "status": "A",
        "authorized_official_last_name": "NICCOLE",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "310-792-3914",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "CA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PTAN",
            "identifier": "F1929",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SOUTH COAST OUTPATIENT SURGERY CENTER",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Smart Therapeutic Services
• Socaltreatmentcentersllc
• Ihab Ibrahim Soliman, M.D.
• Lee Howard Solow, PH.D.
• South Coast Fitter, LLC
• Andrew W Spath, DDS
• Devan Stetson
• Barry Sussman, M.D.
• Stephen Sutherland, M.D.
• Rokhsareh Roxanne Tajrishi, M.D.

• Ambulatory Surgical Clinic/Center in Corona del Mar, CA
• Providers in Corona del Mar, CA by specialty
• Ambulatory Surgical Clinic/Center in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 30, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.