Provider Demographics
NPI:1831279884
Name:CITIZENS MEDICAL GROUP
Entity Type:Organization
Organization Name:CITIZENS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-464-1336
Mailing Address - Street 1:1300 N LA BREA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028
Mailing Address - Country:US
Mailing Address - Phone:323-464-1336
Mailing Address - Fax:323-464-2163
Practice Address - Street 1:1300 N LA BREA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028
Practice Address - Country:US
Practice Address - Phone:323-464-1336
Practice Address - Fax:323-464-2163
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITIZENS MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-16
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ815802Medicaid
CAW4242AMedicare PIN
CAZZZ815802Medicaid