Healthcare Provider Details

I. General information

NPI: 1326575812
Provider Name (Legal Business Name): EXECUTIVE INTERGRATED MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 07/21/2022
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 LONG BEACH BLVD STE 304
LONG BEACH CA
90807-6018
US

IV. Provider business mailing address

3605 LONG BEACH BLVD STE 304
LONG BEACH CA
90807-6018
US

V. Phone/Fax

Practice location:
  • Phone: 310-559-5916
  • Fax: 310-559-5466
Mailing address:
  • Phone: 310-559-5916
  • Fax: 310-559-5466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberA109162
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberA109162
License Number StateCA

VIII. Authorized Official

Name: DR. KAMAL BIJANPOUR
Title or Position: PRESIDENT / CEO
Credential: MD
Phone: 310-559-5916