Provider Demographics
NPI:1033312004
Name:LASER ENDOSCOPY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:LASER ENDOSCOPY MEDICAL GROUP, INC.
Other - Org Name:RICHARD M. DWYER, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DWYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-483-2470
Mailing Address - Street 1:201 S ALVARADO ST
Mailing Address - Street 2:SUITE 407
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2320
Mailing Address - Country:US
Mailing Address - Phone:213-483-2470
Mailing Address - Fax:213-483-0476
Practice Address - Street 1:201 S ALVARADO ST
Practice Address - Street 2:SUITE 407
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2320
Practice Address - Country:US
Practice Address - Phone:213-483-2470
Practice Address - Fax:213-483-0476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0009251Medicaid
CAGR0009250Medicaid
CAGR0009251Medicaid
CAW5176FMedicare ID - Type Unspecified