Provider Demographics
NPI:1356479877
Name:LONG TERM CARE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:LONG TERM CARE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-499-1233
Mailing Address - Street 1:807 N VAN NESS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93728-3425
Mailing Address - Country:US
Mailing Address - Phone:559-499-1233
Mailing Address - Fax:559-499-1232
Practice Address - Street 1:807 N VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93728-3425
Practice Address - Country:US
Practice Address - Phone:559-499-1233
Practice Address - Fax:559-499-1232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G647490207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ34299ZMedicare ID - Type Unspecified