Provider Demographics
NPI:1750728663
Name:BALDWIN PARK MEDICAL CLINIC INC
Entity type:Organization
Organization Name:BALDWIN PARK MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-960-3753
Mailing Address - Street 1:14051 RAMONA PKWY
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-4114
Mailing Address - Country:US
Mailing Address - Phone:626-960-3753
Mailing Address - Fax:626-962-9866
Practice Address - Street 1:14051 RAMONA PKWY
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-4114
Practice Address - Country:US
Practice Address - Phone:626-960-3753
Practice Address - Fax:626-962-9866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-31
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62452174400000X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG62452Medicaid
CAG62452Medicaid