Provider Demographics
NPI:1881764298
Name:PEDIATRIC MEDICAL CENTER
Entity type:Organization
Organization Name:PEDIATRIC MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:P
Authorized Official - Last Name:THERIOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-426-5551
Mailing Address - Street 1:2921 REDONDO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2415
Mailing Address - Country:US
Mailing Address - Phone:562-426-5551
Mailing Address - Fax:562-426-9977
Practice Address - Street 1:2921 REDONDO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2415
Practice Address - Country:US
Practice Address - Phone:562-426-5551
Practice Address - Fax:562-426-9977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0079270Medicaid