1720035686 NPI number — LOS ALAMITOS INTERNAL MEDICAL GROUP INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720035686 NPI number — LOS ALAMITOS INTERNAL MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOS ALAMITOS INTERNAL MEDICAL GROUP INC
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:
6
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:
1720035686
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5300 KATELLA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ALAMITOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90720-2808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-430-7533
Provider Business Mailing Address Fax Number:
562-430-8055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5300 KATELLA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ALAMITOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90720-2808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-430-7533
Provider Business Practice Location Address Fax Number:
562-430-8055
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FORMAN
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
562-430-7533

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A73497 , 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: 00G338210 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00A452500 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00G472290 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00G853440 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00G658950 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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