Basic Information
| Provider Information | |||||||||
| NPI: | 1144361171 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TIGER VALLEY MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5486 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928635486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185500900 | ||||||||
| FaxNumber: | 5052931524 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 W TEMPLE ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900265421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139896100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2007 | ||||||||
| LastUpdateDate: | 08/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | CHORN | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8185500900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GR0092830 | 05 | CA | MEDICAID | ZZZ04655Z | 01 | CA | BLUE SHIELD | OTHER |