Provider Demographics
NPI:1891898862
Name:LONG BEACH NEUROLOGICAL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:LONG BEACH NEUROLOGICAL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:LUBENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-426-3319
Mailing Address - Street 1:PO BOX 91567
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90809-1567
Mailing Address - Country:US
Mailing Address - Phone:562-225-0178
Mailing Address - Fax:562-988-5901
Practice Address - Street 1:2880 ATLANTIC AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1714
Practice Address - Country:US
Practice Address - Phone:562-426-3319
Practice Address - Fax:562-490-3584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG329892084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA45376Medicare UPIN