Provider Demographics
NPI:1396793196
Name:SYMED-CAL MEDICAL GROUP
Entity type:Organization
Organization Name:SYMED-CAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, CREDENTIALING ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-370-3651
Mailing Address - Street 1:55 HATCHETTS HILL RD
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-1534
Mailing Address - Country:US
Mailing Address - Phone:800-370-3651
Mailing Address - Fax:877-515-7147
Practice Address - Street 1:818 W 7TH ST FL 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-3407
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:877-515-7147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGNP000140Medicaid
CADE3373OtherRAILROAD MEDICARE
CADE3373OtherRAILROAD MEDICARE
CAGNP000140Medicaid
CACV606AMedicare PIN