Provider Demographics
NPI:1467640409
Name:GENESIS FAMILY CARE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:GENESIS FAMILY CARE MEDICAL GROUP, INC.
Other - Org Name:PACIFIC COAST FAMILY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:RUBY
Authorized Official - Last Name:J.
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-545-6627
Mailing Address - Street 1:1101 N SEPULVEDA BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5962
Mailing Address - Country:US
Mailing Address - Phone:310-545-6627
Mailing Address - Fax:310-545-0352
Practice Address - Street 1:1101 N SEPULVEDA BLVD STE 102
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5962
Practice Address - Country:US
Practice Address - Phone:310-545-6627
Practice Address - Fax:310-545-0352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34101207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0064100Medicaid
CAW13398BMedicare PIN