Provider Demographics
NPI:1740308717
Name:TALBERT MEDICAL GROUP, P.C.
Entity type:Organization
Organization Name:TALBERT MEDICAL GROUP, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:310-674-3807
Mailing Address - Fax:310-674-3810
Practice Address - Street 1:644 E REGENT ST
Practice Address - Street 2:STE. 100
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1433
Practice Address - Country:US
Practice Address - Phone:310-674-3807
Practice Address - Fax:310-674-3810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA033021OtherBUSINESS LICENSE