Healthcare Provider Details

I. General information

NPI: 1427203785
Provider Name (Legal Business Name): SOUTH MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2008
Last Update Date: 11/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 E SOUTH ST
LONG BEACH CA
90805-4341
US

IV. Provider business mailing address

1530 E SOUTH ST
LONG BEACH CA
90805-4341
US

V. Phone/Fax

Practice location:
  • Phone: 562-984-9200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. KWABENA OBENG
Title or Position: ADMINISTRATOR
Credential:
Phone: 310-800-7963