Basic Information
| Provider Information | |||||||||
| NPI: | 1558447813 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CMG MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | CMG MEDICAL GROUP INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 HIGUERA ST | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934012917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055434043 | ||||||||
| FaxNumber: | 8055434427 | ||||||||
| Practice Location | |||||||||
| Address1: | 2238 BAYVIEW HEIGHTS DR | ||||||||
| Address2: | SUITE G | ||||||||
| City: | LOS OSOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934023921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055341305 | ||||||||
| FaxNumber: | 8055341346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2006 | ||||||||
| LastUpdateDate: | 09/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | GOODMAN | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8055434043 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C1935201 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0069891 | 05 | CA | MEDICAID | ZZZ54101Z | 01 | CA | BLUE SHIELD OF CA | OTHER |