Provider Demographics
NPI:1225314107
Name:WELLCARE MEDICAL GROUP
Entity Type:Organization
Organization Name:WELLCARE MEDICAL GROUP
Other - Org Name:WELLCARE LA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-531-0015
Mailing Address - Street 1:16415 S COLORADO AVENUE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-5054
Mailing Address - Country:US
Mailing Address - Phone:562-531-0015
Mailing Address - Fax:562-531-4856
Practice Address - Street 1:16415 S COLORADO AVENUE
Practice Address - Street 2:SUITE 208
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-5054
Practice Address - Country:US
Practice Address - Phone:562-531-0015
Practice Address - Fax:562-531-4856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
CAA85452207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty