=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326575812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXECUTIVE INTERGRATED MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3605 LONG BEACH BLVD STE 304
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90807-6018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-559-5916
-----------------------------------------------------
Fax | 310-559-5466
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3605 LONG BEACH BLVD STE 304
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90807-6018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-559-5916
-----------------------------------------------------
Fax | 310-559-5466
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT / CEO
-----------------------------------------------------
Name | DR. KAMAL BIJANPOUR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 310-559-5916
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0805X
-----------------------------------------------------
Taxonomy Name | Geriatric Psychiatry Physician
-----------------------------------------------------
License Number | A109162
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0802X
-----------------------------------------------------
Taxonomy Name | Addiction Psychiatry Physician
-----------------------------------------------------
License Number | A109162
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------