Healthcare Provider Details

I. General information

NPI: 1417722232
Provider Name (Legal Business Name): AMG, A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2023
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4528 SLAUSON AVE
MAYWOOD CA
90270-2934
US

IV. Provider business mailing address

4528 SLAUSON AVE
MAYWOOD CA
90270-2934
US

V. Phone/Fax

Practice location:
  • Phone: 213-792-4456
  • Fax:
Mailing address:
  • Phone: 213-792-4456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: THOMAS S. LAM
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 626-943-6228