=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578973392
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOSTON MEDICAL GROUP-NEW JERSEY, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2014
-----------------------------------------------------
Last Update Date | 05/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 WALL STREET WEST, SUITE 120
-----------------------------------------------------
City | LYNDHURST
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-200-6616
-----------------------------------------------------
Fax | 949-258-5076
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23275 S POINT DRIVE SUITE 100
-----------------------------------------------------
City | LAGUNA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-542-9241
-----------------------------------------------------
Fax | 443-542-9442
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | MR. TOM L. LE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 818-808-2828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------