Basic Information
| Provider Information | |||||||||
| NPI: | 1265530653 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S HOSPITAL LOS ANGELES MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 WILSHIRE BLVD. STE. 600 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233612337 | ||||||||
| FaxNumber: | 3233618491 | ||||||||
| Practice Location | |||||||||
| Address1: | 4650 SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233612337 | ||||||||
| FaxNumber: | 3233618491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 11/12/2019 | ||||||||
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| AuthorizedOfficialLastName: | SADAMITSU | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3233612106 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | GR0066679 | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | GR006667D | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | GR0066674 | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | GR0066675 | 05 | CA | MEDICAID | GR0066677 | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | GR006667E | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | GR0066671 | 01 | CA | MEDICAID & CALOPTIMA GROU | OTHER | GR006667B | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | GR006667C | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | G9087701 | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | GR0066676 | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | GR006667F | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | GR0066678 | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | GR0066670 | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | GR0066675 | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | GR006667A | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | GR0066672 | 01 | CA | MEDICAID & CALOPTIMA GROU | OTHER | GR0066673 | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER | GR006667G | 01 | CA | MEDICAID AND CALOPTIMA GR | OTHER |