Provider Demographics
NPI:1366454639
Name:IMPERIAL FAMILY MEDICAL GROUP, A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:IMPERIAL FAMILY MEDICAL GROUP, A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HSU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-861-3111
Mailing Address - Street 1:12651 LAKEWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-4563
Mailing Address - Country:US
Mailing Address - Phone:562-861-3111
Mailing Address - Fax:562-861-9721
Practice Address - Street 1:12651 LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-4563
Practice Address - Country:US
Practice Address - Phone:562-861-3111
Practice Address - Fax:562-861-9721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15800Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER