Basic Information
| Provider Information | |||||||||
| NPI: | 1154377075 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOMA LINDA UNIVERSITY PHYSICIANS MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE NUMBER 56994 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900746994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583111 | ||||||||
| FaxNumber: | 9095583905 | ||||||||
| Practice Location | |||||||||
| Address1: | 11375 ANDERSON ST | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095582624 | ||||||||
| FaxNumber: | 9095583905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 12/14/2007 | ||||||||
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| AuthorizedOfficialLastName: | COUPERUS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT LLU PHYSICIANS MED GROUP | ||||||||
| AuthorizedOfficialTelephone: | 9095582191 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOMA LINDA UNIVERSITY PHYSICANS MEDICAL GROUP | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0040445 | 05 | CA | MEDICAID |