Basic Information
| Provider Information | |||||||||
| NPI: | 1770142440 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BAY PSYCHIATRIC GROUP, A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4570 | ||||||||
| Address2: | |||||||||
| City: | PALOS VERDES PENINSULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902749607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4244007748 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2776 PACIFIC AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908062613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629972000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2019 | ||||||||
| LastUpdateDate: | 06/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | GESSESSE | ||||||||
| AuthorizedOfficialFirstName: | HIRUY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4244007748 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.