Provider Demographics
NPI:1376076620
Name:BACK TO WORK ORTHOPEDIC MEDICAL GROUP
Entity Type:Organization
Organization Name:BACK TO WORK ORTHOPEDIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-616-1166
Mailing Address - Street 1:7300 ALONDRA BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-4000
Mailing Address - Country:US
Mailing Address - Phone:562-531-8300
Mailing Address - Fax:562-531-8035
Practice Address - Street 1:7300 ALONDRA BLVD
Practice Address - Street 2:STE 100
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-4000
Practice Address - Country:US
Practice Address - Phone:562-616-1166
Practice Address - Fax:562-616-1141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization