Provider Demographics
NPI:1558660126
Name:YOUR COMMUNITY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:YOUR COMMUNITY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:MCMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:562-928-9700
Mailing Address - Street 1:6300 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:BELL GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90201-8900
Mailing Address - Country:US
Mailing Address - Phone:562-928-9700
Mailing Address - Fax:562-928-8300
Practice Address - Street 1:6300 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:BELL GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90201-8900
Practice Address - Country:US
Practice Address - Phone:562-928-9700
Practice Address - Fax:562-928-8300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39834261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC39834OtherSTATE LIC NUMBER
CA00C398340Medicaid
CA00C398341Medicaid
CA00C398341Medicaid