Provider Demographics
NPI:1033116546
Name:NEUROMEDICAL DIAGNOSTIC MEDICAL GROUP
Entity Type:Organization
Organization Name:NEUROMEDICAL DIAGNOSTIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:PANOS
Authorized Official - Middle Name:Z
Authorized Official - Last Name:MARMARELIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-591-1324
Mailing Address - Street 1:1045 ATLANTIC AVE
Mailing Address - Street 2:719
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3412
Mailing Address - Country:US
Mailing Address - Phone:562-591-1324
Mailing Address - Fax:562-437-1054
Practice Address - Street 1:1045 ATLANTIC AVE
Practice Address - Street 2:719
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3412
Practice Address - Country:US
Practice Address - Phone:562-591-1324
Practice Address - Fax:562-437-1054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP2733OtherRAIL ROAD MEDICARE
CAW6126OtherPTAN PROVIDER IDENTIFIER, MEDICARE
CAGR0004090Medicaid