Provider Demographics
NPI:1821099227
Name:AXMINSTER MEDICAL GROUP
Entity Type:Organization
Organization Name:AXMINSTER MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-792-4060
Mailing Address - Street 1:4314 W. SLAUSON AVENUE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043
Mailing Address - Country:US
Mailing Address - Phone:310-792-4060
Mailing Address - Fax:
Practice Address - Street 1:4314 W SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-2854
Practice Address - Country:US
Practice Address - Phone:323-293-7171
Practice Address - Fax:323-295-7963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0084740Medicaid
CAZZZ17769ZOtherBLUE SHIELD
CA5204670004Medicare NSC
CAGR0084740Medicaid