Provider Demographics
NPI:1851565337
Name:CITIZENS MEDICAL GROUP
Entity Type:Organization
Organization Name:CITIZENS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-477-8285
Mailing Address - Street 1:11560 W. PICO BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064
Mailing Address - Country:US
Mailing Address - Phone:310-477-8285
Mailing Address - Fax:310-477-9642
Practice Address - Street 1:11560 W. PICO BLVD
Practice Address - Street 2:
Practice Address - City:WEST LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064
Practice Address - Country:US
Practice Address - Phone:310-477-8285
Practice Address - Fax:310-477-9642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29636207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44095Medicare UPIN
CAW4242AMedicare PIN