Provider Demographics
NPI:1417976705
Name:GREATER LONG BEACH GENITO-URINARY MED GRP
Entity Type:Organization
Organization Name:GREATER LONG BEACH GENITO-URINARY MED GRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JULES
Authorized Official - Middle Name:M
Authorized Official - Last Name:PERLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-630-0423
Mailing Address - Street 1:3650 SOUTH STREET
Mailing Address - Street 2:SUITE 408
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-1510
Mailing Address - Country:US
Mailing Address - Phone:562-630-0423
Mailing Address - Fax:562-630-0660
Practice Address - Street 1:3650 SOUTH STREET
Practice Address - Street 2:SUITE 408
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1510
Practice Address - Country:US
Practice Address - Phone:562-630-0423
Practice Address - Fax:562-630-0660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22223208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG22223BOtherMEDICARE INDIVIDUAL PROVI
CAWG54806DOtherMEDICARE INDIVIDUAL PROVI
CA1497724900OtherPHYSICIAN INDIVIDUAL PIN
CA1326017831OtherPHYSICIAN INDIVIDUAL UPIN
CAWA76527BOtherMEDICARE INDIVIDUAL PROVI
CAWG54806COtherMEDICARE INDIVIDUAL PROVI
CAG22223OtherSTATE LICENSE
CAG54806OtherSTATE LICENSE
CA1801865381OtherPHYSICIAN INDIVIDUAL PIN
CAA76527OtherSTATE LICENSE
CAGR0049180Medicaid
CAWA76527AOtherMEDICARE INDIVIDUAL PROVI
CAWG22223AOtherMEDICARE INDIVIDUAL PROVI
CAWA76527AOtherMEDICARE INDIVIDUAL PROVI
CAG54806OtherSTATE LICENSE
CAG22223OtherSTATE LICENSE
CAWG22223AOtherMEDICARE INDIVIDUAL PROVI
CAW8676EMedicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER #
CAW8676Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER #