=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558447813
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CMG MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2006
-----------------------------------------------------
Last Update Date | 09/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2238 BAYVIEW HEIGHTS DR SUITE G
-----------------------------------------------------
City | LOS OSOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93402-3921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-534-1305
-----------------------------------------------------
Fax | 805-534-1346
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1555 HIGUERA ST
-----------------------------------------------------
City | SAN LUIS OBISPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93401-2917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-543-4043
-----------------------------------------------------
Fax | 805-543-4427
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | STEVEN B GOODMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 805-543-4043
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | C1935201
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------