Basic Information
| Provider Information | |||||||||
| NPI: | 1285642033 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHRIDGE FAMILY PRACTICE MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18406 ROSCOE BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188855480 | ||||||||
| FaxNumber: | 8188855430 | ||||||||
| Practice Location | |||||||||
| Address1: | 18406 ROSCOE BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188855480 | ||||||||
| FaxNumber: | 8188855430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 11/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8188855480 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.