Basic Information
| Provider Information | |||||||||
| NPI: | 1508897463 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TARZANA ANESTHESIA MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11999 SAN VICENTE BLVD | ||||||||
| Address2: | #440 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900495131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104403131 | ||||||||
| FaxNumber: | 3104713958 | ||||||||
| Practice Location | |||||||||
| Address1: | 18321 CLARK ST | ||||||||
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| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913563501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104403131 | ||||||||
| FaxNumber: | 3104713958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MIKHAIL | ||||||||
| AuthorizedOfficialFirstName: | MOKHTAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8187085285 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.