Healthcare Provider Details

I. General information

NPI: 1770142440
Provider Name (Legal Business Name): SOUTH BAY PSYCHIATRIC GROUP, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2776 PACIFIC AVE
LONG BEACH CA
90806-2613
US

IV. Provider business mailing address

PO BOX 4570
PALOS VERDES PENINSULA CA
90274-9607
US

V. Phone/Fax

Practice location:
  • Phone: 562-997-2000
  • Fax:
Mailing address:
  • Phone: 424-400-7748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. HIRUY GESSESSE
Title or Position: PRESIDENT
Credential: MD
Phone: 424-400-7748