Healthcare Provider Details

I. General information

NPI: 1831332865
Provider Name (Legal Business Name): CHILDRENS GASTROENTEROLOGY MCSG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 04/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 TERMINO AVE SUITE 300
LONG BEACH CA
90804-2105
US

IV. Provider business mailing address

PO BOX 20360
LONG BEACH CA
90801-3360
US

V. Phone/Fax

Practice location:
  • Phone: 562-933-6900
  • Fax: 562-933-8557
Mailing address:
  • Phone: 562-933-6900
  • Fax: 562-933-8557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberA24038
License Number StateCA

VIII. Authorized Official

Name: DR. RICHARD K MATHIS
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 562-933-6900