Provider Demographics
NPI:1003296369
Name:ADVANCED MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:ADVANCED MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ESKAROUS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:6082-132-8363
Mailing Address - Street 1:510 N PROSPECT AVE
Mailing Address - Street 2:STE 306
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 N PROSPECT AVE
Practice Address - Street 2:STE 306
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3028
Practice Address - Country:US
Practice Address - Phone:310-376-7555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-02
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC55850207Q00000X
CAE4996213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty