Provider Demographics
NPI:1417343690
Name:PHYSICIAN ASSOCIATES MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:PHYSICIAN ASSOCIATES MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-790-8100
Mailing Address - Street 1:151 N KRAEMER BLVD
Mailing Address - Street 2:STE: 100
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-5002
Mailing Address - Country:US
Mailing Address - Phone:562-790-8100
Mailing Address - Fax:562-790-8114
Practice Address - Street 1:23183 LA CADENA DR STE 103
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1449
Practice Address - Country:US
Practice Address - Phone:562-790-8100
Practice Address - Fax:562-790-8114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-14
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty