Basic Information
Provider Information | |||||||||
NPI: | 1548303589 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PIONEER MEDICAL GROUP INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1682 | ||||||||
Address2: |   | ||||||||
City: | BELLFLOWER | ||||||||
State: | CA | ||||||||
PostalCode: | 907071682 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5622299452 | ||||||||
FaxNumber: | 5629204642 | ||||||||
Practice Location | |||||||||
Address1: | 10251 ARTESIA BLVD | ||||||||
Address2: |   | ||||||||
City: | BELLFLOWER | ||||||||
State: | CA | ||||||||
PostalCode: | 907066719 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5622299452 | ||||||||
FaxNumber: | 5629204642 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2007 | ||||||||
LastUpdateDate: | 11/01/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WONG | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5622299452 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | CJ3784 | 01 | CA | RAILROAD MEDICARE | OTHER |