Provider Demographics
NPI:1760406250
Name:COMPREHENSIVE UROLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:COMPREHENSIVE UROLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-278-8330
Mailing Address - Street 1:8631 W 3RD ST STE 1115E
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5901
Mailing Address - Country:US
Mailing Address - Phone:310-278-8330
Mailing Address - Fax:310-278-7595
Practice Address - Street 1:8631 W 3RD ST STE 1115E
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5901
Practice Address - Country:US
Practice Address - Phone:310-278-8330
Practice Address - Fax:310-278-7595
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMPREHENSIVE UROLOGY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-27
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG183300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19095Medicare ID - Type Unspecified