Basic Information
| Provider Information | |||||||||
| NPI: | 1922470392 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ONE MEDICAL GROUP, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ONE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 SUTTER ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941044015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156586791 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3615 JACK NORTHROP AVE. | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HAWTHORNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103001051 | ||||||||
| FaxNumber: | 3103001052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2015 | ||||||||
| LastUpdateDate: | 10/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4156586791 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ONE MEDICAL GROUP, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.