Provider Demographics
NPI:1932155165
Name:LOMA LINDA UNIVERSITY PHYSICIANS MEDICAL GROUP INC
Entity Type:Organization
Organization Name:LOMA LINDA UNIVERSITY PHYSICIANS MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT LLU PHYSICIANS MEDICAL GR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:COUPERUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-558-2191
Mailing Address - Street 1:FILE NUMBER 56994
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-6994
Mailing Address - Country:US
Mailing Address - Phone:909-558-3111
Mailing Address - Fax:909-558-3905
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:STE.1405
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-8762
Practice Address - Fax:909-558-3905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0040454Medicaid
CAGR0040454Medicaid