Provider Demographics
NPI:1760532543
Name:COLLEGE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:COLLEGE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SOMSONG
Authorized Official - Middle Name:WATTANASAKUL
Authorized Official - Last Name:TONGBAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-564-9323
Mailing Address - Street 1:611 S MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-5715
Mailing Address - Country:US
Mailing Address - Phone:714-564-9323
Mailing Address - Fax:714-973-8885
Practice Address - Street 1:611 S MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5715
Practice Address - Country:US
Practice Address - Phone:714-564-9323
Practice Address - Fax:714-973-8885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31437261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A314370-151OtherCALOPTIMA PROVIDER NUMBER
CAGR0011541OtherCHDP PROVIDER NUMBER
CAGR0011541OtherMEDI-CAL PROVIDER NUMBER