MEDICARE: CROWN CITY MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician		CA

General Provider Information

NPI Number	:	1073512836
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWN CITY MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	2661 E WASHINGTON BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-1412
Country	:	US
Telephone Number	:	626-798-8792
Fax Number	:	626-296-1403

Provider Business Practice Location Address
First Line	:	2661 E WASHINGTON BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-1412
Country	:	US
Telephone Number	:	626-798-4952
Fax Number	:	626-296-1403

Authorized Official
Title or Position	:	MIDICAL DIRECTOR
Name	:	KEVIN B. TYSON
Credential	:	M.D.
Telephone Number	:	626-798-8792

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	07/28/2014

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