Provider Demographics
NPI:1841465150
Name:PACIFIC MEDICAL GROUP
Entity type:Organization
Organization Name:PACIFIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-796-8181
Mailing Address - Street 1:48 N EL MOLINO AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1861
Mailing Address - Country:US
Mailing Address - Phone:626-796-8181
Mailing Address - Fax:626-796-1874
Practice Address - Street 1:48 N EL MOLINO AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1861
Practice Address - Country:US
Practice Address - Phone:626-796-8181
Practice Address - Fax:626-796-1874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40994207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0057870Medicaid
CAGR0057870Medicaid