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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GR0041813	OTHER	CA	MEDI-CAL PROVIDER #

General Provider Information

NPI Number	:	1962525964
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWN CITY MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	1542 E FLORENCE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90001-2536
Country	:	US
Telephone Number	:	323-584-0222
Fax Number	:	626-296-1403

Provider Business Practice Location Address
First Line	:	1542 E FLORENCE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90001-2536
Country	:	US
Telephone Number	:	323-584-0222
Fax Number	:	626-296-1403

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

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	07/28/2014

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