Provider Demographics
NPI:1073662110
Name:PACIFIC SHORES MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PACIFIC SHORES MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NERSES
Authorized Official - Middle Name:SIMON
Authorized Official - Last Name:TCHEKMEDYIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-590-0345
Mailing Address - Street 1:1043 ELM AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3271
Mailing Address - Country:US
Mailing Address - Phone:562-590-0345
Mailing Address - Fax:562-437-8139
Practice Address - Street 1:3747 WORSHAM AVE
Practice Address - Street 2:STE 101
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-1774
Practice Address - Country:US
Practice Address - Phone:562-430-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0065543Medicaid
CA1118450003Medicare NSC
CAW13494AMedicare PIN