Provider Demographics
NPI:1508989500
Name:CROWN CITY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CROWN CITY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TYSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-798-8792
Mailing Address - Street 1:6601 RUGBY AVE
Mailing Address - Street 2:# 300
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4040
Mailing Address - Country:US
Mailing Address - Phone:323-582-1177
Mailing Address - Fax:323-589-2635
Practice Address - Street 1:6601 RUGBY AVE
Practice Address - Street 2:# 300
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4040
Practice Address - Country:US
Practice Address - Phone:323-582-1177
Practice Address - Fax:323-589-2635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0041811OtherMEDI-CAL PROVIDER #
CAW12163AMedicare ID - Type Unspecified