Basic Information
| Provider Information | |||||||||
| NPI: | 1184662405 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FACULTY MEDICAL GROUP OF LLUSM | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE NUMBER 54701 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900744701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11234 ANDERSON ST | ||||||||
| Address2: | A 108 | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584344 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | PEVERINI | ||||||||
| AuthorizedOfficialFirstName: | RICARDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT FACULTY MEDICAL GROUP OF | ||||||||
| AuthorizedOfficialTelephone: | 9095587448 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0068913 | 05 | CA | MEDICAID |