Provider Demographics
NPI:1316971351
Name:PENINSULA PULMONARY MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:PENINSULA PULMONARY MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-378-8900
Mailing Address - Street 1:3701 SKYPARK DR
Mailing Address - Street 2:#200
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4753
Mailing Address - Country:US
Mailing Address - Phone:310-378-8900
Mailing Address - Fax:310-791-0786
Practice Address - Street 1:3701 SKYPARK DR
Practice Address - Street 2:#200
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4753
Practice Address - Country:US
Practice Address - Phone:310-378-8900
Practice Address - Fax:310-791-0786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14741Medicare ID - Type Unspecified