Provider Demographics
NPI:1013188721
Name:ST JOHN MEDICAL GROUP INC
Entity Type:Organization
Organization Name:ST JOHN MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:YOUSSEF
Authorized Official - Middle Name:
Authorized Official - Last Name:AWAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-568-6770
Mailing Address - Street 1:3530 LONG BEACH BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3972
Mailing Address - Country:US
Mailing Address - Phone:562-989-1200
Mailing Address - Fax:
Practice Address - Street 1:3530 LONG BEACH BLVD STE 120
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3972
Practice Address - Country:US
Practice Address - Phone:562-989-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52194207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty