Basic Information
| Provider Information | |||||||||
| NPI: | 1477625671 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BUENA PARK MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 277 | ||||||||
| Address2: | |||||||||
| City: | BUENA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906210277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149945290 | ||||||||
| FaxNumber: | 7149948090 | ||||||||
| Practice Location | |||||||||
| Address1: | 6301 BEACH BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BUENA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906212840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149945290 | ||||||||
| FaxNumber: | 7149948090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | AHN | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | TAEHUNG | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7149945290 | ||||||||
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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 | 207Q00000X | A85576 | CA | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A061574 | CA | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | G53693 | CA | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | A63728 | CA | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A637280 | 05 | CA | MEDICAID | GR0099930 | 05 | CA | MEDICAID | 00A855760 | 05 | CA | MEDICAID | 00A615740 | 05 | CA | MEDICAID | 00G536930 | 05 | CA | MEDICAID |