Provider Demographics
NPI:1306820758
Name:OCEAN MEDICAL FAMILY AND URGENT CARE MEDICAL CORPORATION INC
Entity Type:Organization
Organization Name:OCEAN MEDICAL FAMILY AND URGENT CARE MEDICAL CORPORATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-316-1661
Mailing Address - Street 1:1106 S PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277
Mailing Address - Country:US
Mailing Address - Phone:310-316-1661
Mailing Address - Fax:310-316-1846
Practice Address - Street 1:1106 S PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277
Practice Address - Country:US
Practice Address - Phone:310-316-1661
Practice Address - Fax:310-316-1846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11631Medicare ID - Type Unspecified
E36033Medicare UPIN