Basic Information
| Provider Information | |||||||||
| NPI: | 1851575765 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTAMED HEALTH SERVICES CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALTAMED MEDICAL GROUP AIDS WAIVER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2040 CAMFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900401501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237258751 | ||||||||
| FaxNumber: | 3238897843 | ||||||||
| Practice Location | |||||||||
| Address1: | 5427 WHITTIER BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900224101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238695448 | ||||||||
| FaxNumber: | 3238695433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2007 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | U. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, PATIENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3236222429 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALTAMED HEALTH SERVICES CORP. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | AYD000440 | CA | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | AYD000440 | 01 | CA | AIDS WAIVER PROGRAM | OTHER |