Provider Demographics
NPI:1215037049
Name:PACIFIC PALISADES MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:PACIFIC PALISADES MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-459-7736
Mailing Address - Street 1:15200 W SUNSET BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3619
Mailing Address - Country:US
Mailing Address - Phone:310-459-7736
Mailing Address - Fax:310-230-0284
Practice Address - Street 1:15200 W SUNSET BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3619
Practice Address - Country:US
Practice Address - Phone:310-459-7736
Practice Address - Fax:310-230-0284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17834Medicare ID - Type Unspecified