Provider Demographics
NPI:1770505620
Name:INNLEY MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:INNLEY MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HAZEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKILLOP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-914-9150
Mailing Address - Street 1:4253 REDONDO BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-3341
Mailing Address - Country:US
Mailing Address - Phone:310-914-9150
Mailing Address - Fax:310-914-9705
Practice Address - Street 1:4253 REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-3341
Practice Address - Country:US
Practice Address - Phone:310-914-9150
Practice Address - Fax:310-914-9705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50837207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A508371Medicaid
CAG30207Medicare UPIN
CA00A508371Medicaid