Provider Demographics
NPI:1558447813
Name:CMG MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CMG MEDICAL GROUP INC
Other - Org Name:CMG MEDICAL GROUP INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-543-4043
Mailing Address - Street 1:1555 HIGUERA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2917
Mailing Address - Country:US
Mailing Address - Phone:805-543-4043
Mailing Address - Fax:805-543-4427
Practice Address - Street 1:2238 BAYVIEW HEIGHTS DR
Practice Address - Street 2:SUITE G
Practice Address - City:LOS OSOS
Practice Address - State:CA
Practice Address - Zip Code:93402-3921
Practice Address - Country:US
Practice Address - Phone:805-534-1305
Practice Address - Fax:805-534-1346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-30
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1935201207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0069891Medicaid
CAZZZ54101ZOtherBLUE SHIELD OF CA
W13933AMedicare PIN
CACH6045Medicare PIN