MEDICARE: LONG BEACH PRIME 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	207X00000X	Orthopaedic Surgery Physician		CA

General Provider Information

NPI Number	:	1205955986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONG BEACH PRIME MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	4014 LONG BEACH BLVD
Second Line	:	#210
City	:	LONG BEACH
State	:	CA
Zip	:	90807-5407
Country	:	US
Telephone Number	:	562-997-7100
Fax Number	:	562-981-9423

Provider Business Practice Location Address
First Line	:	4014 LONG BEACH BLVD
Second Line	:	#210
City	:	LONG BEACH
State	:	CA
Zip	:	90807-5407
Country	:	US
Telephone Number	:	562-997-7100
Fax Number	:	562-981-9423

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	G.B. HAERI
Credential	:	MD
Telephone Number	:	562-997-7100

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	07/21/2022

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