Healthcare Provider Details

I. General information

NPI: 1003296369
Provider Name (Legal Business Name): ADVANCED MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 N PROSPECT AVE STE 306
REDONDO BEACH CA
90277-3028
US

IV. Provider business mailing address

510 N PROSPECT AVE STE 306
REDONDO BEACH CA
90277-3028
US

V. Phone/Fax

Practice location:
  • Phone: 310-376-7555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC55850
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE4996
License Number StateCA

VIII. Authorized Official

Name: MICHAEL ESKAROUS
Title or Position: SECRETARY
Credential: DPM
Phone: 60821328363