Provider Demographics
NPI:1528071008
Name:GENESIS FAMILY CARE MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:GENESIS FAMILY CARE MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF GROUP
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-545-6627
Mailing Address - Street 1:1101 N SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5948
Mailing Address - Country:US
Mailing Address - Phone:310-545-6627
Mailing Address - Fax:310-545-0352
Practice Address - Street 1:520 N PROSPECT AVENUE
Practice Address - Street 2:SUITE 102
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3041
Practice Address - Country:US
Practice Address - Phone:310-374-7655
Practice Address - Fax:310-372-7026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13398AMedicare PIN