Basic Information
| Provider Information | |||||||||
| NPI: | 1356409072 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | L & G MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7156 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952670156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094676866 | ||||||||
| FaxNumber: | 2094676865 | ||||||||
| Practice Location | |||||||||
| Address1: | 1205 E NORTH ST | ||||||||
| Address2: | |||||||||
| City: | MANTECA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953364932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098233111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 02/12/2009 | ||||||||
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| AuthorizedOfficialLastName: | GHOLAMI | ||||||||
| AuthorizedOfficialFirstName: | SAEED | ||||||||
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| AuthorizedOfficialTitleorPosition: | INCORPORATOR | ||||||||
| AuthorizedOfficialTelephone: | 9542555200 | ||||||||
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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 | 207L00000X | G74551 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G745512 | 05 | CA | MEDICAID |