Provider Demographics
NPI:1720171325
Name:TALBERT MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:TALBERT MEDICAL GROUP, P.C.
Other - Org Name:TALBERT MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:LIETHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-205-6262
Mailing Address - Street 1:P.O. BOX 6400
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-6400
Mailing Address - Country:US
Mailing Address - Phone:310-783-5552
Mailing Address - Fax:310-783-5581
Practice Address - Street 1:3650 SOUTH ST
Practice Address - Street 2:STE 303
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1502
Practice Address - Country:US
Practice Address - Phone:562-633-9734
Practice Address - Fax:562-633-9753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4143OtherBUSINESS LICENSE
CAW13900PMedicare PIN