Provider Demographics
NPI:1528000866
Name:MERIDIAN MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:MERIDIAN MEDICAL GROUP, P.C.
Other - Org Name:CENTINELA MEDICAL CENTER CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:C
Authorized Official - Last Name:DIKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-434-4626
Mailing Address - Street 1:20300 S VERMONT AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-1334
Mailing Address - Country:US
Mailing Address - Phone:323-434-4626
Mailing Address - Fax:310-693-8082
Practice Address - Street 1:20300 S VERMONT AVE STE 215
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-1334
Practice Address - Country:US
Practice Address - Phone:323-295-5062
Practice Address - Fax:310-693-8082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0043390Medicaid
CAGR0043390Medicaid
CADX765BMedicare PIN