Provider Demographics
NPI:1689863995
Name:1ST INDUSTRIAL MEDICAL GROUP
Entity Type:Organization
Organization Name:1ST INDUSTRIAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENNALLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-289-4693
Mailing Address - Street 1:1234 W CHAPMAN AVE
Mailing Address - Street 2:SUITE # 204
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2862
Mailing Address - Country:US
Mailing Address - Phone:714-289-4693
Mailing Address - Fax:714-289-4698
Practice Address - Street 1:1234 W CHAPMAN AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2862
Practice Address - Country:US
Practice Address - Phone:714-289-4693
Practice Address - Fax:714-289-4698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty