Provider Demographics
NPI:1689680001
Name:MEMORIAL FAMILY MEDICINE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MEMORIAL FAMILY MEDICINE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:Y
Authorized Official - Last Name:MELVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:562-933-0055
Mailing Address - Street 1:450 E SPRING ST
Mailing Address - Street 2:#1
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-1625
Mailing Address - Country:US
Mailing Address - Phone:562-933-0050
Mailing Address - Fax:562-933-0079
Practice Address - Street 1:450 E SPRING ST
Practice Address - Street 2:#1
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1625
Practice Address - Country:US
Practice Address - Phone:562-933-0050
Practice Address - Fax:562-933-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0071000Medicaid
CAW13857Medicare ID - Type Unspecified
CAGR0071000Medicaid