Provider Demographics
NPI:1104430669
Name:PACIFIC MEDICAL GROUP
Entity type:Organization
Organization Name:PACIFIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMSON
Authorized Official - Middle Name:
Authorized Official - Last Name:YIRGU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-305-9200
Mailing Address - Street 1:4712 ADMIRALTY WAY # 574
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6905
Mailing Address - Country:US
Mailing Address - Phone:310-305-9200
Mailing Address - Fax:310-305-2800
Practice Address - Street 1:5450 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:PLAYA VISTA
Practice Address - State:CA
Practice Address - Zip Code:90094-2002
Practice Address - Country:US
Practice Address - Phone:310-305-9200
Practice Address - Fax:310-305-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty