Basic Information
| Provider Information | |||||||||
| NPI: | 1497759005 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TALBERT MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6400 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905040400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107835552 | ||||||||
| FaxNumber: | 3107835581 | ||||||||
| Practice Location | |||||||||
| Address1: | 1665 SCENIC AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926261443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103544221 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 04/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | MARGOLIS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | C.E.O. | ||||||||
| AuthorizedOfficialTelephone: | 3103544221 | ||||||||
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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 | 302R00000X | FNP26902 | CA | Y | Managed Care Organizations | Health Maintenance Organization |
ID Information
| ID | Type | State | Issuer | Description | W13900 | 01 | CA | MEDICARE | OTHER |