1417976705 NPI number — GREATER LONG BEACH GENITO-URINARY MED GRP

Table of content: (NPI 1417976705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417976705 NPI number — GREATER LONG BEACH GENITO-URINARY MED GRP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREATER LONG BEACH GENITO-URINARY MED GRP
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:
1417976705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3650 SOUTH STREET
Provider Second Line Business Mailing Address:
SUITE 408
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90712-1510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-630-0423
Provider Business Mailing Address Fax Number:
562-630-0660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3650 SOUTH STREET
Provider Second Line Business Practice Location Address:
SUITE 408
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90712-1510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-630-0423
Provider Business Practice Location Address Fax Number:
562-630-0660
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PERLEY
Authorized Official First Name:
JULES
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MD/PRESIDENT
Authorized Official Telephone Number:
562-630-0423

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  G22223 , 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: WG22223B . This is a "MEDICARE INDIVIDUAL PROVI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: WG54806D . This is a "MEDICARE INDIVIDUAL PROVI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1497724900 . This is a "PHYSICIAN INDIVIDUAL PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1326017831 . This is a "PHYSICIAN INDIVIDUAL UPIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: WA76527B . This is a "MEDICARE INDIVIDUAL PROVI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: WG54806C . This is a "MEDICARE INDIVIDUAL PROVI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G22223 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G54806 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1801865381 . This is a "PHYSICIAN INDIVIDUAL PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: A76527 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0049180 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: WA76527A . This is a "MEDICARE INDIVIDUAL PROVI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: WG22223A . This is a "MEDICARE INDIVIDUAL PROVI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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