Provider Demographics
NPI:1174683643
Name:ORTHOPAEDIC MEDICAL GROUP & ATHLETIC REHABILITATION CENTER, INC
Entity Type:Organization
Organization Name:ORTHOPAEDIC MEDICAL GROUP & ATHLETIC REHABILITATION CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:O
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-918-6655
Mailing Address - Street 1:1050 LAKES DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2929
Mailing Address - Country:US
Mailing Address - Phone:626-918-6655
Mailing Address - Fax:626-918-6633
Practice Address - Street 1:1050 LAKES DR
Practice Address - Street 2:STE 100
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790
Practice Address - Country:US
Practice Address - Phone:626-918-6655
Practice Address - Fax:626-918-6633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0048931OtherMEDICAL
CAZZZ16473ZOtherBLUE SHIELD OF CA
CAGR0048930Medicaid
CADB7567Medicare PIN
CAGR0048930Medicaid
CAGR0048932Medicare PIN
CA0860620003Medicare NSC
CAW744Medicare PIN
CAZZZ16473ZOtherBLUE SHIELD OF CA
CA0860620002Medicare NSC
CAZZZ20891ZMedicare PIN
CAW744BMedicare PIN
CACN3371Medicare PIN