Provider Demographics
NPI:1760665772
Name:EVERGREEN MEDICAL GROUP
Entity Type:Organization
Organization Name:EVERGREEN MEDICAL GROUP
Other - Org Name:EVERGREEN PUENTE HILLS URGENT CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:FAN YANG
Authorized Official - Last Name:TZENG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-965-8202
Mailing Address - Street 1:1850 S AZUSA AVE
Mailing Address - Street 2:SUITE 60
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6813
Mailing Address - Country:US
Mailing Address - Phone:626-965-8202
Mailing Address - Fax:626-964-9893
Practice Address - Street 1:1850 S AZUSA AVE
Practice Address - Street 2:SUITE 60
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-6813
Practice Address - Country:US
Practice Address - Phone:626-965-8202
Practice Address - Fax:626-964-9893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39498261Q00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0054080Medicaid
CAGR0054080Medicaid