MEDICARE: ARDMORE 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	207V00000X	Obstetrics & Gynecology Physician	G82337	CA

General Provider Information

NPI Number	:	1447342142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARDMORE MEDICAL GROUP

Provider Business Mailing Address
First Line	:	5953 ATLANTIC BLVD
Second Line	:
City	:	MAYWOOD
State	:	CA
Zip	:	90270
Country	:	US
Telephone Number	:	323-562-6170
Fax Number	:	323-562-6176

Provider Business Practice Location Address
First Line	:	2765 E FLORENCE AVE
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255
Country	:	US
Telephone Number	:	323-588-6888
Fax Number	:	323-588-0087

Authorized Official
Title or Position	:	PRESIDENT MD
Name	:	ALAN K KIMS
Credential	:	MD
Telephone Number	:	323-562-6170

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	08/22/2020

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