Provider Demographics
NPI:1639540560
Name:PROFESSIONAL ADVANTAGE MEDICAL GROUP
Entity Type:Organization
Organization Name:PROFESSIONAL ADVANTAGE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMBOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-233-2228
Mailing Address - Street 1:38713 TIERRA SUBIDA AVE
Mailing Address - Street 2:SUITE 200-315
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-4562
Mailing Address - Country:US
Mailing Address - Phone:850-233-2228
Mailing Address - Fax:714-985-9053
Practice Address - Street 1:1041 E YORBA LINDA BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-3728
Practice Address - Country:US
Practice Address - Phone:714-985-9110
Practice Address - Fax:714-985-9053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-19
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87090208D00000X
208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty