MEDICARE: GREEN PEACE MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A33409	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003801648
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN PEACE MEDICAL GROUP

Provider Business Mailing Address
First Line	:	330 W LAS TUNAS DR
Second Line	:	SUITE 3
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-1213
Country	:	US
Telephone Number	:	626-573-0055
Fax Number	:	626-573-4087

Provider Business Practice Location Address
First Line	:	330 W LAS TUNAS DR
Second Line	:	SUITE 3
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-1213
Country	:	US
Telephone Number	:	626-573-0055
Fax Number	:	626-573-4087

Authorized Official
Title or Position	:	OWNER
Name	:	SHENG H CHANG
Credential	:	MD
Telephone Number	:	626-573-0055

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	06/16/2008

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