Provider Demographics
NPI:1326575812
Name:EXECUTIVE INTERGRATED MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:EXECUTIVE INTERGRATED MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:BIJANPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-559-5916
Mailing Address - Street 1:3605 LONG BEACH BLVD STE 304
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-6018
Mailing Address - Country:US
Mailing Address - Phone:310-559-5916
Mailing Address - Fax:310-559-5466
Practice Address - Street 1:3605 LONG BEACH BLVD STE 304
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-6018
Practice Address - Country:US
Practice Address - Phone:310-559-5916
Practice Address - Fax:310-559-5466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084P0800X
CAA1091622084P0802X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty