Provider Demographics
NPI:1790873776
Name:ARDMORE MEDICAL GROUP
Entity type:Organization
Organization Name:ARDMORE MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:KIMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-562-6170
Mailing Address - Street 1:5953 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90270
Mailing Address - Country:US
Mailing Address - Phone:323-562-6170
Mailing Address - Fax:323-562-6176
Practice Address - Street 1:3518 W 8TH STREET
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005
Practice Address - Country:US
Practice Address - Phone:213-384-9949
Practice Address - Fax:213-384-2530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty