Provider Demographics
NPI:1205955986
Name:LONG BEACH PRIME MEDICAL GROUP INC
Entity type:Organization
Organization Name:LONG BEACH PRIME MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:G.B.
Authorized Official - Middle Name:
Authorized Official - Last Name:HAERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-997-7100
Mailing Address - Street 1:4014 LONG BEACH BLVD
Mailing Address - Street 2:#210
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-5407
Mailing Address - Country:US
Mailing Address - Phone:562-997-7100
Mailing Address - Fax:562-981-9423
Practice Address - Street 1:4014 LONG BEACH BLVD
Practice Address - Street 2:#210
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-5407
Practice Address - Country:US
Practice Address - Phone:562-997-7100
Practice Address - Fax:562-981-9423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID