Provider Demographics
NPI:1144221631
Name:TALBERT MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:TALBERT MEDICAL GROUP, P.C.
Other - Org Name:TALBERT MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:LIETHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-205-6262
Mailing Address - Street 1:P.O. BOX 6400
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-6400
Mailing Address - Country:US
Mailing Address - Phone:310-783-5552
Mailing Address - Fax:310-783-5581
Practice Address - Street 1:2925 PALO VERDE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-1552
Practice Address - Country:US
Practice Address - Phone:562-429-2473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133V00000X, 174400000X, 207K00000X, 207N00000X, 207P00000X, 207Q00000X, 207R00000X, 207V00000X, 207Y00000X, 208000000X, 2085R0202X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0077869Medicaid
CAW13900HMedicare ID - Type Unspecified