Provider Demographics
NPI:1194930420
Name:MODERN CONCEPTS MEDICAL GROUP
Entity type:Organization
Organization Name:MODERN CONCEPTS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:HERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-728-6070
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-0640
Mailing Address - Country:US
Mailing Address - Phone:323-728-6070
Mailing Address - Fax:323-728-2912
Practice Address - Street 1:50 BELLEFONTAINE ST
Practice Address - Street 2:404
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3132
Practice Address - Country:US
Practice Address - Phone:323-728-6070
Practice Address - Fax:323-728-2912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0936983OtherCLIA WAIVER
CA6495234Medicaid
CAGR0084064Medicaid
CA1346358827OtherMD
CA05D0936983OtherCLIA WAIVER
CAQ46422Medicare UPIN
CA6495234Medicaid
CAS63567Medicare UPIN
CAH74215Medicare UPIN
CAS38353Medicare UPIN
CAW14041AMedicare PIN
CAG73418Medicare UPIN
CAH88710Medicare UPIN