1447515911 NPI number — PROPRIUS HEALTH MEDICAL GROUP PC

Table of content: (NPI 1447515911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447515911 NPI number — PROPRIUS HEALTH MEDICAL GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROPRIUS HEALTH MEDICAL GROUP PC
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:
1447515911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3939 ATLANTIC AVE STE 223
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90807-3535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-633-1765
Provider Business Mailing Address Fax Number:
495-028-8879

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3939 ATLANTIC AVE STE 223
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-633-1765
Provider Business Practice Location Address Fax Number:
949-502-8887
Provider Enumeration Date:
07/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DOKUKIN
Authorized Official First Name:
ANDREI
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
917-647-5031

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , with the licence number:  A110631 , 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: 05D2048806 . This is a "CLIA WAIVED CERTIFICATE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: C3423023 . This is a "SECRETARY OF STATE CORPORATION NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ70684Y . This is a "BLUE SHIELD OF CALIFORNIA GROUP PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 43221 . This is a "CA MEDICAL BOARD- FICTITIOUS NAME PERMIT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CLR00343337 . This is a "CA CLINICAL LAB REGISTRATION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: BU21223680 . This is a "CITY OF LONG BEACH BUSINESS LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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