Provider Demographics
NPI:1518105923
Name:BENEVEDA MEDICAL GROUP
Entity Type:Organization
Organization Name:BENEVEDA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOM
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOBE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-550-1378
Mailing Address - Street 1:50 N LA CIENEGA BLVD
Mailing Address - Street 2:STE 215
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211
Mailing Address - Country:US
Mailing Address - Phone:310-289-2800
Mailing Address - Fax:310-652-6251
Practice Address - Street 1:50 N LA CIENEGA BLVD
Practice Address - Street 2:STE 215
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211
Practice Address - Country:US
Practice Address - Phone:310-289-2800
Practice Address - Fax:310-652-6251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-23
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 208D00000X
CAG88065207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty