Basic Information
| Provider Information | |||||||||
| NPI: | 1417248840 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHAMPION MEDICAL GROUP, A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2980 N BEVERLY GLEN CIR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900771726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104749809 | ||||||||
| FaxNumber: | 8884318819 | ||||||||
| Practice Location | |||||||||
| Address1: | 8121 VAN NUYS BLVD | ||||||||
| Address2: | STE 316 | ||||||||
| City: | PANORAMA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914025105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189941102 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2011 | ||||||||
| LastUpdateDate: | 10/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | MARSHAK | ||||||||
| AuthorizedOfficialFirstName: | HERBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3104749809 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHAMPION MEDICAL GROUP, A MEDICAL CORPORATION | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.