Basic Information
| Provider Information | |||||||||
| NPI: | 1356899777 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARTIN LUTHER KING JR COMMUNITY MEDICAL GROUP ROSECRANS | ||||||||
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| OtherOrganizationName: | MARTIN LUTHER KING, JR. COMMUNITY MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2251 W ROSECRANS AVE STE 18-21 | ||||||||
| Address2: | |||||||||
| City: | COMPTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902223858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4243388760 | ||||||||
| FaxNumber: | 4242963976 | ||||||||
| Practice Location | |||||||||
| Address1: | 2251 W ROSECRANS AVE | ||||||||
| Address2: | UNIT 21 | ||||||||
| City: | COMPTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902223858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4245296755 | ||||||||
| FaxNumber: | 4243388984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | STAUDER | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4243388760 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207VM0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 171R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Interpreter | 172V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Community Health Worker | 183500000X | N | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207QA0401X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207QA0505X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.