1033116546 NPI number — NEUROMEDICAL DIAGNOSTIC MEDICAL GROUP

Table of content: DENEEN P. BROOKS MSW, LCSW, LSW, SWII (NPI 1174328488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033116546 NPI number — NEUROMEDICAL DIAGNOSTIC MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROMEDICAL DIAGNOSTIC MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033116546
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1045 ATLANTIC AVE
Provider Second Line Business Mailing Address:
719
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90813-3412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-591-1324
Provider Business Mailing Address Fax Number:
562-437-1054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1045 ATLANTIC AVE
Provider Second Line Business Practice Location Address:
719
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90813-3412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-591-1324
Provider Business Practice Location Address Fax Number:
562-437-1054
Provider Enumeration Date:
06/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MARMARELIS
Authorized Official First Name:
PANOS
Authorized Official Middle Name:
Z
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
562-591-1324

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CP2733 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: W6126 . This is a "PTAN PROVIDER IDENTIFIER, MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0004090 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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