Provider Demographics
NPI:1184798316
Name:HONOLULU MEDICAL GROUP
Entity type:Organization
Organization Name:HONOLULU MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-537-2211
Mailing Address - Street 1:550 S BERETANIA ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2496
Mailing Address - Country:US
Mailing Address - Phone:808-537-2211
Mailing Address - Fax:
Practice Address - Street 1:550 S BERETANIA ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2496
Practice Address - Country:US
Practice Address - Phone:808-537-2211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-5757261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI026245-03Medicaid
HIMD5757OtherMDX
HI896441OtherUHA
HI504423OtherHMN
HI5838611OtherFIRST HEALTH
HI5838611OtherFIRST HEALTH
HI026245-03Medicaid