Healthcare Provider Details

I. General information

NPI: 1972792729
Provider Name (Legal Business Name): RONALD J. PHILIPP, D.O. A PROF CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 N LAKEWOOD BLVD
LONG BEACH CA
90815-2507
US

IV. Provider business mailing address

2255 N LAKEWOOD BLVD
LONG BEACH CA
90815-2507
US

V. Phone/Fax

Practice location:
  • Phone: 562-498-8000
  • Fax: 562-494-8880
Mailing address:
  • Phone: 562-498-8000
  • Fax: 562-494-8880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number20A6919
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number20A4777
License Number StateCA

VIII. Authorized Official

Name: DR. RONALD J. PHILIPP
Title or Position: PHYSICIAN/OWNER
Credential: D.O.
Phone: 562-498-8000