Provider Demographics
NPI:1255414546
Name:MEMORIAL ORTHOPAEDIC SURGICAL GROUP
Entity type:Organization
Organization Name:MEMORIAL ORTHOPAEDIC SURGICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LIANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-424-6666
Mailing Address - Street 1:2760 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2755
Mailing Address - Country:US
Mailing Address - Phone:562-424-6666
Mailing Address - Fax:562-424-7122
Practice Address - Street 1:2760 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2755
Practice Address - Country:US
Practice Address - Phone:562-424-6666
Practice Address - Fax:562-424-7122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW8640Medicare ID - Type Unspecified
CAG13646Medicare UPIN
CA0421330001Medicare NSC
CAI02890Medicare UPIN
CAA52711Medicare UPIN
CAA28164Medicare UPIN
CAW8640Medicare PIN
CAA43082Medicare UPIN
CAT10788Medicare UPIN
CAA38936Medicare UPIN
CAE80480Medicare UPIN
CAA48272Medicare UPIN
CAH21428Medicare UPIN