Healthcare Provider Details

I. General information

NPI: 1265473672
Provider Name (Legal Business Name): UNITED PHYSICIAN MULTISPECIALTY GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 E PACIFIC COAST HWY
WILMINGTON CA
90744-2726
US

IV. Provider business mailing address

1930 WILSHIRE BLVD SUITE 410
LOS ANGELES CA
90057-3605
US

V. Phone/Fax

Practice location:
  • Phone: 310-549-6950
  • Fax:
Mailing address:
  • Phone: 213-413-4203
  • Fax: 213-413-5615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG39326
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberFNP34335
License Number StateCA

VIII. Authorized Official

Name: RANDALL HRABKO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 213-413-4203