Provider Demographics
NPI:1164588141
Name:PARKLANE MEDICAL GROUP
Entity Type:Organization
Organization Name:PARKLANE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:IFEORAH
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:310-367-3107
Mailing Address - Street 1:933 CENTINELA AVE
Mailing Address - Street 2:B
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90302-1501
Mailing Address - Country:US
Mailing Address - Phone:310-677-5090
Mailing Address - Fax:310-677-7302
Practice Address - Street 1:933 CENTINELA AVE
Practice Address - Street 2:B
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90302-1501
Practice Address - Country:US
Practice Address - Phone:310-677-5090
Practice Address - Fax:310-677-7302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102061Medicaid