Provider Demographics
NPI:1336355320
Name:PARKLANE MEDICAL GROUP
Entity Type:Organization
Organization Name:PARKLANE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:C
Authorized Official - Last Name:IFEORAH
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:310-637-3989
Mailing Address - Street 1:508 NORTH LONG BEACH BL.
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221
Mailing Address - Country:US
Mailing Address - Phone:310-637-3989
Mailing Address - Fax:310-637-9325
Practice Address - Street 1:508 NORTH LONG BEACH BL.
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221
Practice Address - Country:US
Practice Address - Phone:310-637-3989
Practice Address - Fax:310-637-9325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102060Medicaid