Healthcare Provider Details

I. General information

NPI: 1528113149
Provider Name (Legal Business Name): LOS ANGELES MULTISPECIALTY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 N LOCUST ST
INGLEWOOD CA
90301-1258
US

IV. Provider business mailing address

PO BOX 83246
LOS ANGELES CA
90083-0246
US

V. Phone/Fax

Practice location:
  • Phone: 310-680-1810
  • Fax: 310-680-1811
Mailing address:
  • Phone: 310-680-1810
  • Fax: 310-680-1811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC38014
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: RANDALL WHITAKER MAXEY
Title or Position: PRESIDENT
Credential: MD
Phone: 310-680-1810