MEDICARE: DR. BAO THAI NGUYEN MD

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	208100000X	Physical Medicine & Rehabilitation Physician	A95636	CA
2	208100000X	Physical Medicine & Rehabilitation Physician	252803-2	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1194913756	OTHER	CA	NPI

General Provider Information

NPI Number	:	1194913756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BAO THAI NGUYEN MD

Provider Business Mailing Address
First Line	:	555 PIER AVE
Second Line	:	SUITE #1
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-3839
Country	:	US
Telephone Number	:	424-488-0500
Fax Number	:	424-488-0498

Provider Business Practice Location Address
First Line	:	555 PIER AVE
Second Line	:	SUITE #1
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-3839
Country	:	US
Telephone Number	:	424-488-0500
Fax Number	:	424-488-0498

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	02/10/2015

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