Basic Information
| Provider Information | |||||||||
| NPI: | 1134251192 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROHEALTH PARTNERS, A MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1045 ATLANTIC AVE | ||||||||
| Address2: | SUITE 705 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908133408 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1760 TERMINO AVE STE 214 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908042169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625954718 | ||||||||
| FaxNumber: | 5625917323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | ALLSWANG | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5622995239 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | GR006415A | 05 | CA | MEDICAID | ZZZ51266Z | 01 | CA | BLUE SHIELD GROUP NUMBER | OTHER |