MEDICARE: FIRST INTEGRATED CARE 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	A38544	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720077852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST INTEGRATED CARE MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	1339 W WILLOW ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90810-3116
Country	:	US
Telephone Number	:	562-492-6698
Fax Number	:	562-492-9553

Provider Business Practice Location Address
First Line	:	1339 W WILLOW ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90810-3116
Country	:	US
Telephone Number	:	562-492-6698
Fax Number	:	562-492-9553

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. ELNORA T TABILA
Credential	:	RN
Telephone Number	:	562-492-6698

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	03/05/2021

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