Provider Demographics
NPI:1710084959
Name:AIYEGBUSI AND BRAIMAH MEDICAL CORP.
Entity Type:Organization
Organization Name:AIYEGBUSI AND BRAIMAH MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MODUPE
Authorized Official - Middle Name:
Authorized Official - Last Name:AIYEGBUSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-540-7240
Mailing Address - Street 1:3661 TORRANCE BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4812
Mailing Address - Country:US
Mailing Address - Phone:310-540-7240
Mailing Address - Fax:310-540-7280
Practice Address - Street 1:3661 TORRANCE BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4812
Practice Address - Country:US
Practice Address - Phone:310-540-7240
Practice Address - Fax:310-540-7280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0090260Medicaid
CAW15244Medicare ID - Type UnspecifiedGROUP MEDICARE ID NUMBER