Provider Demographics
NPI:1649602384
Name:CROWN CITY MEDICAL GROUP
Entity type:Organization
Organization Name:CROWN CITY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:TYSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-798-8792
Mailing Address - Street 1:2589 E WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1446
Mailing Address - Country:US
Mailing Address - Phone:626-798-8792
Mailing Address - Fax:626-296-1403
Practice Address - Street 1:1800 N WESTERN AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411
Practice Address - Country:US
Practice Address - Phone:909-887-3087
Practice Address - Fax:909-887-2974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty