Provider Demographics
NPI:1831332865
Name:CHILDRENS GASTROENTEROLOGY MCSG
Entity type:Organization
Organization Name:CHILDRENS GASTROENTEROLOGY MCSG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:K
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-933-6900
Mailing Address - Street 1:PO BOX 20360
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90801-3360
Mailing Address - Country:US
Mailing Address - Phone:562-933-6900
Mailing Address - Fax:562-933-8557
Practice Address - Street 1:1760 TERMINO AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2105
Practice Address - Country:US
Practice Address - Phone:562-933-6900
Practice Address - Fax:562-933-8557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA240382080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A549840OtherDR. SELA-HERMAN IND MEDICAL NUMBER
CA00A240380OtherDR. MATHIS IND MEDI-CAL NUMBER