Basic Information
| Provider Information | |||||||||
| NPI: | 1093023780 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HUNTINGTON TRAUMA SURGERY MED GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80248 | ||||||||
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| City: | SAN MARINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911188248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267684415 | ||||||||
| FaxNumber: | 6267684421 | ||||||||
| Practice Location | |||||||||
| Address1: | 1044 S FAIR OAKS AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911052622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264494859 | ||||||||
| FaxNumber: | 6264030311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2010 | ||||||||
| LastUpdateDate: | 09/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | OBAID | ||||||||
| AuthorizedOfficialFirstName: | AMAL | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6266833030 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A75419 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | FNP32017 | 01 | CA | FICTITIOUS NAME PERMIT | OTHER |