Basic Information
Provider Information | |||||||||
NPI: | 1699212977 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PIH HEALTH PHYSICIANS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BRIGHT HEALTH PHYSICIANS OF PIH | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1277 | ||||||||
Address2: |   | ||||||||
City: | WHITTIER | ||||||||
State: | CA | ||||||||
PostalCode: | 906091277 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5627895401 | ||||||||
FaxNumber: | 5627895912 | ||||||||
Practice Location | |||||||||
Address1: | 12675 LA MIRADA BLVD STE 201&220 | ||||||||
Address2: |   | ||||||||
City: | LA MIRADA | ||||||||
State: | CA | ||||||||
PostalCode: | 906382200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5629037339 | ||||||||
FaxNumber: | 5629672931 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2017 | ||||||||
LastUpdateDate: | 10/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MIYAMOTO | ||||||||
AuthorizedOfficialFirstName: | KEITH | ||||||||
AuthorizedOfficialMiddleName: | S. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5627895401 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 10/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QH0002X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.