Provider Demographics
NPI:1245317411
Name:MEDICAL GROUP ASSOCIATES INC
Entity type:Organization
Organization Name:MEDICAL GROUP ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRECIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-652-2255
Mailing Address - Street 1:8501 WILSHIRE BLVD
Mailing Address - Street 2:316
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-3101
Mailing Address - Country:US
Mailing Address - Phone:310-652-2255
Mailing Address - Fax:310-652-3580
Practice Address - Street 1:8501 WILSHIRE BLVD
Practice Address - Street 2:316
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-3101
Practice Address - Country:US
Practice Address - Phone:310-652-2255
Practice Address - Fax:310-652-3580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC27493261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ87633ZOtherBLUE SHIELD
CAGR0006640Medicaid
CAW7283Medicare PIN