Healthcare Provider Details

I. General information

NPI: 1720171325
Provider Name (Legal Business Name): TALBERT MEDICAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 SOUTH ST STE 303
LAKEWOOD CA
90712-1502
US

IV. Provider business mailing address

P.O. BOX 6400
TORRANCE CA
90504-6400
US

V. Phone/Fax

Practice location:
  • Phone: 562-633-9734
  • Fax: 562-633-9753
Mailing address:
  • Phone: 310-783-5552
  • Fax: 310-783-5581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: JOHN G. LIETHEN
Title or Position: SECRETARY
Credential:
Phone: 952-205-6262