Provider Demographics
NPI:1942756937
Name:CITY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CITY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:ONOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-531-0915
Mailing Address - Street 1:PO BOX 881916
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90009
Mailing Address - Country:US
Mailing Address - Phone:323-531-0915
Mailing Address - Fax:
Practice Address - Street 1:1508 FLORENCE AVENUE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90009
Practice Address - Country:US
Practice Address - Phone:323-531-0915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY MEDICAL GROW INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP14622207Q00000X
CAA118311207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA118311Medicaid