MEDICARE: GREATER LONG BEACH GENITO-URINARY MED GRP

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	208800000X	Urology Physician	G22223	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	WG22223B	OTHER	CA	MEDICARE INDIVIDUAL PROVI
2	WG54806D	OTHER	CA	MEDICARE INDIVIDUAL PROVI
5	WA76527B	OTHER	CA	MEDICARE INDIVIDUAL PROVI
6	WG54806C	OTHER	CA	MEDICARE INDIVIDUAL PROVI
12	WA76527A	OTHER	CA	MEDICARE INDIVIDUAL PROVI
13	WG22223A	OTHER	CA	MEDICARE INDIVIDUAL PROVI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	1497724900	OTHER	CA	PHYSICIAN INDIVIDUAL PIN
4	1326017831	OTHER	CA	PHYSICIAN INDIVIDUAL UPIN
7	G22223	OTHER	CA	STATE LICENSE
8	G54806	OTHER	CA	STATE LICENSE
9	1801865381	OTHER	CA	PHYSICIAN INDIVIDUAL PIN
10	A76527	OTHER	CA	STATE LICENSE
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417976705
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREATER LONG BEACH GENITO-URINARY MED GRP

Provider Business Mailing Address
First Line	:	3650 SOUTH STREET
Second Line	:	SUITE 408
City	:	LAKEWOOD
State	:	CA
Zip	:	90712-1510
Country	:	US
Telephone Number	:	562-630-0423
Fax Number	:	562-630-0660

Provider Business Practice Location Address
First Line	:	3650 SOUTH STREET
Second Line	:	SUITE 408
City	:	LAKEWOOD
State	:	CA
Zip	:	90712-1510
Country	:	US
Telephone Number	:	562-630-0423
Fax Number	:	562-630-0660

Authorized Official
Title or Position	:	MD/PRESIDENT
Name	:	DR. JULES M PERLEY
Credential	:	MD
Telephone Number	:	562-630-0423

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	01/15/2010

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