MEDICARE: SAN ANGEL MEDICAL CLINIC, 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	A44599	CA
2	208000000X	Pediatrics Physician	A52088	CA
3	363A00000X	Physician Assistant	PA15560	CA
4	207V00000X	Obstetrics & Gynecology Physician	G86496	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699975557
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN ANGEL MEDICAL CLINIC, INC.

Provider Business Mailing Address
First Line	:	2661 E FLORENCE AVE
Second Line	:	SUUITE D-1
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4793
Country	:	US
Telephone Number	:	323-588-6113
Fax Number	:

Provider Business Practice Location Address
First Line	:	2661 E FLORENCE AVE
Second Line	:	SUUITE D-1
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4793
Country	:	US
Telephone Number	:	323-588-6113
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	STEPHINE KRAMER
Credential	:	M.D.
Telephone Number	:	323-588-6113

Provider Enumeration Date	:	07/19/2007
Last Update Date	:	09/20/2013

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