Provider Demographics
NPI:1780755280
Name:MEMORIAL SPORTS & INTERNAL MEDICINE
Entity type:Organization
Organization Name:MEMORIAL SPORTS & INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRYSANTHIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALEXANDRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-795-6406
Mailing Address - Street 1:10861 CHERRY ST
Mailing Address - Street 2:200
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-5402
Mailing Address - Country:US
Mailing Address - Phone:562-795-6406
Mailing Address - Fax:562-795-6409
Practice Address - Street 1:10861 CHERRY ST
Practice Address - Street 2:200
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-5402
Practice Address - Country:US
Practice Address - Phone:562-795-6406
Practice Address - Fax:562-795-6409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16800Medicare PIN