Basic Information
| Provider Information | |||||||||
| NPI: | 1811273576 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CMG MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 HIGUERA STREET | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBSIPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934012917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055434043 | ||||||||
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| Practice Location | |||||||||
| Address1: | 265 POSADA LANE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934654056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054340900 | ||||||||
| FaxNumber: | 8054349260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2011 | ||||||||
| LastUpdateDate: | 10/26/2011 | ||||||||
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| AuthorizedOfficialLastName: | GOODMAN | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8055434043 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CMG MEDICAL GROUP INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G51256 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.