MEDICARE: CROWN CITY 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GR0041812	OTHER	CA	MEDI-CAL PROVIDER #

General Provider Information

NPI Number	:	1619090610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWN CITY MEDICAL GROUP INC.

Provider Business Mailing Address
First Line	:	3208 SANTA ANITA AVE
Second Line	:	# 200
City	:	EL MONTE
State	:	CA
Zip	:	91733-1360
Country	:	US
Telephone Number	:	626-454-1990
Fax Number	:	626-454-1995

Provider Business Practice Location Address
First Line	:	3208 SANTA ANITA AVE
Second Line	:	# 200
City	:	EL MONTE
State	:	CA
Zip	:	91733-1360
Country	:	US
Telephone Number	:	626-454-1990
Fax Number	:	626-454-1995

Authorized Official
Title or Position	:	CEO
Name	:	MAUREEN B. TYSON
Credential	:
Telephone Number	:	626-798-8792

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	08/22/2020

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Directions to “CROWN CITY MEDICAL GROUP INC. ” Practice Location

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