MEDICARE: BLUE OAK MEDICAL GROUP

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	261QX0100X	Occupational Medicine Clinic/Center

General Provider Information

NPI Number	:	1154788131
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE OAK MEDICAL GROUP

Provider Business Mailing Address
First Line	:	10801 NATIONAL BLVD STE 401
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-4143
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5860 AVALON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90003
Country	:	US
Telephone Number	:	909-204-6612
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	ROBIN CHORN
Credential	:	MD
Telephone Number	:	424-258-5716

Provider Enumeration Date	:	01/22/2016
Last Update Date	:	09/04/2018

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