Provider Demographics
NPI:1073512836
Name:CROWN CITY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:CROWN CITY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MIDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:TYSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-798-8792
Mailing Address - Street 1:2661 E WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1412
Mailing Address - Country:US
Mailing Address - Phone:626-798-8792
Mailing Address - Fax:626-296-1403
Practice Address - Street 1:2661 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1412
Practice Address - Country:US
Practice Address - Phone:626-798-4952
Practice Address - Fax:626-296-1403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW12163Medicare ID - Type Unspecified