Provider Demographics
NPI:1396858122
Name:CALIFORNIA CARDIOTHORACIC ASSOCIATES MEDICAL GRP
Entity Type:Organization
Organization Name:CALIFORNIA CARDIOTHORACIC ASSOCIATES MEDICAL GRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:WONG
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-603-6562
Mailing Address - Street 1:11500 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 409
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6218
Mailing Address - Country:US
Mailing Address - Phone:310-826-2073
Mailing Address - Fax:310-826-9353
Practice Address - Street 1:3630 E IMPERIAL HWY
Practice Address - Street 2:SUITE 2101
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2636
Practice Address - Country:US
Practice Address - Phone:310-826-2073
Practice Address - Fax:310-826-9353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0078730Medicaid
CAGR0078730Medicaid