Healthcare Provider Details

I. General information

NPI: 1073662110
Provider Name (Legal Business Name): PACIFIC SHORES MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3747 WORSHAM AVE STE 101
LONG BEACH CA
90808-1774
US

IV. Provider business mailing address

1043 ELM AVE STE 104
LONG BEACH CA
90813-3271
US

V. Phone/Fax

Practice location:
  • Phone: 562-430-5900
  • Fax:
Mailing address:
  • Phone: 562-590-0345
  • Fax: 562-437-8139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: NERSES SIMON TCHEKMEDYIAN
Title or Position: CEO
Credential: M.D.
Phone: 562-590-0345