Basic Information
| Provider Information | |||||||||
| NPI: | 1508139957 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOLDEN STATE BONE AND JOINT CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9033 WILSHIRE BLVD | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902101847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108583800 | ||||||||
| FaxNumber: | 8885896241 | ||||||||
| Practice Location | |||||||||
| Address1: | 9033 WILSHIRE BLVD | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902101847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108583800 | ||||||||
| FaxNumber: | 8885896241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2012 | ||||||||
| LastUpdateDate: | 05/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | ENNA | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3108583880 | ||||||||
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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 | 207XS0106X | A100628 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XX0005X | A100628 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | A100628 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.