Basic Information
Provider Information | |||||||||
NPI: | 1497776355 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AMGAD R ELSIBAI MD INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5486 | ||||||||
Address2: |   | ||||||||
City: | ORANGE | ||||||||
State: | CA | ||||||||
PostalCode: | 928635486 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8185500900 | ||||||||
FaxNumber: | 8185500900 | ||||||||
Practice Location | |||||||||
Address1: | 16055 VENTURA BLVD STE 1000 | ||||||||
Address2: |   | ||||||||
City: | ENCINO | ||||||||
State: | CA | ||||||||
PostalCode: | 914362611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3106211332 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2006 | ||||||||
LastUpdateDate: | 06/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ELSIBAI | ||||||||
AuthorizedOfficialFirstName: | AMGAD | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER PRES | ||||||||
AuthorizedOfficialTelephone: | 3106211332 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 06/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A52784 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 00A527841 | 05 | CA |   | MEDICAID |