Healthcare Provider Details

I. General information

NPI: 1205955986
Provider Name (Legal Business Name): LONG BEACH PRIME MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4014 LONG BEACH BLVD #210
LONG BEACH CA
90807-5407
US

IV. Provider business mailing address

4014 LONG BEACH BLVD #210
LONG BEACH CA
90807-5407
US

V. Phone/Fax

Practice location:
  • Phone: 562-997-7100
  • Fax: 562-981-9423
Mailing address:
  • Phone: 562-997-7100
  • Fax: 562-981-9423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: G.B. HAERI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 562-997-7100