Provider Demographics
NPI:1073795498
Name:LONG BEACH SURGICAL GROUP A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LONG BEACH SURGICAL GROUP A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-436-9645
Mailing Address - Street 1:1040 ELM AVE
Mailing Address - Street 2:SUITE #303
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3264
Mailing Address - Country:US
Mailing Address - Phone:562-436-9645
Mailing Address - Fax:562-436-7119
Practice Address - Street 1:1040 ELM AVE
Practice Address - Street 2:SUITE #303
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3264
Practice Address - Country:US
Practice Address - Phone:562-436-9645
Practice Address - Fax:562-436-7119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC25484174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C254840Medicaid
CAGR0014610Medicaid
CAW045Medicare PIN
CAA32887Medicare UPIN