Provider Demographics
NPI:1528113149
Name:LOS ANGELES MULTISPECIALTY MEDICAL GROUP
Entity type:Organization
Organization Name:LOS ANGELES MULTISPECIALTY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:WHITAKER
Authorized Official - Last Name:MAXEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-680-1810
Mailing Address - Street 1:PO BOX 83246
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90083-0246
Mailing Address - Country:US
Mailing Address - Phone:310-680-1810
Mailing Address - Fax:310-680-1811
Practice Address - Street 1:248 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1258
Practice Address - Country:US
Practice Address - Phone:310-680-1810
Practice Address - Fax:310-680-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC38014207R00000X
207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC30814OtherMED LICENCE