Provider Demographics
NPI:1568642197
Name:BEVERLY INTERNAL MEDICINE MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:BEVERLY INTERNAL MEDICINE MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SOUMITRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SARKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-728-0653
Mailing Address - Street 1:2614 W BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2310
Mailing Address - Country:US
Mailing Address - Phone:323-728-0653
Mailing Address - Fax:
Practice Address - Street 1:2614 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2310
Practice Address - Country:US
Practice Address - Phone:323-728-0653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53499207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA110208996OtherRAILROAD MEDICARE
CA00A534990Medicaid
CA00A534990Medicaid