Provider Demographics
NPI:1265473672
Name:UNITED PHYSICIAN MULTISPECIALTY GROUP INC
Entity Type:Organization
Organization Name:UNITED PHYSICIAN MULTISPECIALTY GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:HRABKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-413-4203
Mailing Address - Street 1:1930 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-3605
Mailing Address - Country:US
Mailing Address - Phone:213-413-4203
Mailing Address - Fax:213-413-5615
Practice Address - Street 1:1037 E PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-2726
Practice Address - Country:US
Practice Address - Phone:310-549-6950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39326207Q00000X
CAFNP34335302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No302F00000XManaged Care OrganizationsExclusive Provider OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19842Medicare PIN