Provider Demographics
NPI:1952311680
Name:ADVANCE SURGEONS MEDICAL GROUP INC
Entity Type:Organization
Organization Name:ADVANCE SURGEONS MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:T
Authorized Official - Last Name:SIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACC
Authorized Official - Phone:626-457-6333
Mailing Address - Street 1:120 W HELLMAN AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-1209
Mailing Address - Country:US
Mailing Address - Phone:626-457-6333
Mailing Address - Fax:626-457-1933
Practice Address - Street 1:120 W HELLMAN AVE STE 203
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1209
Practice Address - Country:US
Practice Address - Phone:626-457-6333
Practice Address - Fax:626-457-1933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0089240Medicaid
CAW15092Medicare ID - Type Unspecified