MEDICARE: CMG MEDICAL GROUP INC

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	1935201	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	ZZZ54100Z	OTHER	CA	BLUE SHIELD OF CA
3	183948201	OTHER		USDOL PROVIDER ID

General Provider Information

NPI Number	:	1134299357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CMG MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	1555 HIGUERA ST
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-2917
Country	:	US
Telephone Number	:	805-543-4043
Fax Number	:	805-543-4427

Provider Business Practice Location Address
First Line	:	5920 WEST MALL
Second Line	:
City	:	ATASCADERO
State	:	CA
Zip	:	93422-4232
Country	:	US
Telephone Number	:	805-466-0676
Fax Number	:	805-466-8276

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STEVEN B GOODMAN
Credential	:	MD
Telephone Number	:	805-543-4043

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	09/16/2011

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