Provider Demographics
NPI:1952323800
Name:GOODFAITH FAMILY MEDICAL GROUP
Entity Type:Organization
Organization Name:GOODFAITH FAMILY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-307-4785
Mailing Address - Street 1:7770 GARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-3061
Mailing Address - Country:US
Mailing Address - Phone:626-307-4785
Mailing Address - Fax:626-307-1019
Practice Address - Street 1:7770 GARVEY AVE
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-3061
Practice Address - Country:US
Practice Address - Phone:626-307-4785
Practice Address - Fax:626-307-1019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49571261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083450Medicaid
CAF74576Medicare UPIN
CAF74579Medicare UPIN
CAF85966Medicare UPIN
CAGR0083450Medicaid