Basic Information
| Provider Information | |||||||||
| NPI: | 1720171325 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TALBERT MEDICAL GROUP, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TALBERT MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 6400 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905046400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107835552 | ||||||||
| FaxNumber: | 3107835581 | ||||||||
| Practice Location | |||||||||
| Address1: | 3650 SOUTH ST | ||||||||
| Address2: | STE 303 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907121502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626339734 | ||||||||
| FaxNumber: | 5626339753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 08/20/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LIETHEN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9522056262 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4143 | 01 | CA | BUSINESS LICENSE | OTHER |