Provider Demographics
NPI:1609086727
Name:PROGRESSIVE MEDICAL GROUP
Entity Type:Organization
Organization Name:PROGRESSIVE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-672-6500
Mailing Address - Street 1:1035 S PRAIRIE AVE
Mailing Address - Street 2:STE. 1
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-5272
Mailing Address - Country:US
Mailing Address - Phone:310-672-6500
Mailing Address - Fax:310-672-6781
Practice Address - Street 1:1035 S PRAIRIE AVE
Practice Address - Street 2:STE. 1
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-5272
Practice Address - Country:US
Practice Address - Phone:310-672-6500
Practice Address - Fax:310-672-6781
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-24
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35959207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty