Provider Demographics
NPI:1578790234
Name:M.A. MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:M.A. MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REUVEN
Authorized Official - Middle Name:F
Authorized Official - Last Name:SISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-607-0333
Mailing Address - Street 1:PO BOX 717
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-0717
Mailing Address - Country:US
Mailing Address - Phone:626-607-0333
Mailing Address - Fax:626-607-0379
Practice Address - Street 1:850 S ATLANTIC BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-4730
Practice Address - Country:US
Practice Address - Phone:626-607-0333
Practice Address - Fax:626-607-0379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31954207N00000X
CAA85883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1225143274OtherREUVEN F SISON NPI