# ORTHOPAEDIC MEDICAL GROUP & ATHLETIC REHABILITATION CENTER, INC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1174683643
- **Authorized official:** THOMAS O BRYAN MD (PRESIDENT)
- **Authorized official phone:** (626) 918-6655

## Contact information

- **Practice address:** 1050 LAKES DR, STE 100, WEST COVINA, CA 91790
- **Practice address phone:** (626) 918-6655
- **Practice address fax:** (626) 918-6633
- **Mailing address:** 1050 LAKES DR STE 100, WEST COVINA, CA 91790-2929
- **Mailing address phone:** (626) 918-6655
- **Mailing address fax:** (626) 918-6633

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207X00000X | Orthopaedic Surgery Physician | — | NULL | Yes |
| 207X00000X | Orthopaedic Surgery Physician | — | — | Yes |
| 2251X0800X | Orthopedic Physical Therapist | — | NULL | — |
| 2251X0800X | Orthopedic Physical Therapist | — | — | — |

## Other

- **Enumeration date:** 12/12/2006
- **Last updated:** 08/27/2015

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | GR0048930 | — | CA |
| 01 | — | GR0048931 | MEDICAL | CA |
| 01 | — | ZZZ16473Z | BLUE SHIELD OF CA | CA |