Healthcare Provider Details

I. General information

NPI: 1073512836
Provider Name (Legal Business Name): CROWN CITY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2661 E WASHINGTON BLVD
PASADENA CA
91107-1412
US

IV. Provider business mailing address

2661 E WASHINGTON BLVD
PASADENA CA
91107-1412
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-4952
  • Fax: 626-296-1403
Mailing address:
  • Phone: 626-798-8792
  • Fax: 626-296-1403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: KEVIN B. TYSON
Title or Position: MIDICAL DIRECTOR
Credential: M.D.
Phone: 626-798-8792