Basic Information
| Provider Information | |||||||||
| NPI: | 1669428595 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOMA LINDA UNIV PHYSICIANS MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE NUMBER 56994 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900746994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583111 | ||||||||
| FaxNumber: | 9095583905 | ||||||||
| Practice Location | |||||||||
| Address1: | 27990 SHERMAN ROAD | ||||||||
| Address2: | |||||||||
| City: | SUN CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516797412 | ||||||||
| FaxNumber: | 9095583905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 10/02/2007 | ||||||||
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| AuthorizedOfficialLastName: | COUPERUS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT LLU PHYSICIANS MEDICAL GR | ||||||||
| AuthorizedOfficialTelephone: | 9095582191 | ||||||||
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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 | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0040443 | 05 | CA | MEDICAID |