Basic Information
| Provider Information | |||||||||
| NPI: | 1518401546 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FACULTY PHYSICIANS AND SURGEONS OF LLUSM | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE # 54701 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900744701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584000 | ||||||||
| FaxNumber: | 9096514352 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 BROCKTON AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925014090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095586388 | ||||||||
| FaxNumber: | 9096514586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2016 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | PEVERINI | ||||||||
| AuthorizedOfficialFirstName: | RICARDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9095582480 | ||||||||
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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 | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.