Provider Demographics
NPI:1043571599
Name:GRAND OB-GYN MEDICAL GROUP INC
Entity Type:Organization
Organization Name:GRAND OB-GYN MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:TUAN TONG
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-625-0615
Mailing Address - Street 1:4950 SAN BERNARDINO ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2328
Mailing Address - Country:US
Mailing Address - Phone:909-625-0615
Mailing Address - Fax:909-621-6735
Practice Address - Street 1:4950 SAN BERNARDINO ST
Practice Address - Street 2:SUTE 106
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2328
Practice Address - Country:US
Practice Address - Phone:909-625-0615
Practice Address - Fax:909-621-6735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37294207VE0102X, 207VX0201X, 208600000X
207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Multi-Specialty
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1477763829Medicaid
CAZZZ05321ZMedicare Oscar/Certification