Provider Demographics
NPI:1942293279
Name:AXMINSTER MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:AXMINSTER MEDICAL GROUP INC.
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 1:12618 HAWTHORNE BLVD.
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-2325
Mailing Address - Country:US
Mailing Address - Phone:310-263-5700
Mailing Address - Fax:
Practice Address - Street 1:12618 HAWTHORNE BLVD.
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-2325
Practice Address - Country:US
Practice Address - Phone:310-263-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2022-07-21
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
CAGR0084741Medicaid
CAZZZ24681ZOtherBLUE SHIELD
CA5204670002Medicare NSC
CAGR0084741Medicaid