Provider Demographics
NPI:1275723629
Name:GREEN, STUART & MARINOW, HARRY & BONFILIO, NICHOLAS & FEIWELL, LAWRENC
Entity Type:Organization
Organization Name:GREEN, STUART & MARINOW, HARRY & BONFILIO, NICHOLAS & FEIWELL, LAWRENC
Other - Org Name:GREATER LONG BEACH ORTHOPAEDIC SURGICAL & MEDICAL GROUP A PTRSHP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:AHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-430-3561
Mailing Address - Street 1:1040 ELM AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3265
Mailing Address - Country:US
Mailing Address - Phone:562-591-4444
Mailing Address - Fax:562-436-7350
Practice Address - Street 1:3771 KATELLA AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3115
Practice Address - Country:US
Practice Address - Phone:562-430-3561
Practice Address - Fax:562-431-8882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0066741Medicaid
W13148AOtherOTHER PTAN
W13148BOtherPTAN
CAZZZ53512ZOtherBLUE SHIELD PIN NUMBER
CAGR0066741Medicaid
CAZZZ53512ZOtherBLUE SHIELD PIN NUMBER