Healthcare Provider Details

I. General information

NPI: 1992430045
Provider Name (Legal Business Name): CYH MEDICAL GROUP (DE), P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4136 DEL REY AVE
MARINA DEL REY CA
90292-5604
US

IV. Provider business mailing address

4136 DEL REY AVE
MARINA DEL REY CA
90292-5604
US

V. Phone/Fax

Practice location:
  • Phone: 410-886-7398
  • Fax:
Mailing address:
  • Phone: 410-886-7398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DANIEL JOHN MONTVILLE
Title or Position: CHIEF MEDICAL OFFICER
Credential:
Phone: 612-805-7008