Basic Information
| Provider Information | |||||||||
| NPI: | 1659385904 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HARRY MARSHAK, M.D., A PROFESSIONAL MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60790 | ||||||||
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| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911166790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267956596 | ||||||||
| FaxNumber: | 6267958247 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 S SPALDING DR | ||||||||
| Address2: | #300 | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902121800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106577600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 06/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | MARSHAK | ||||||||
| AuthorizedOfficialFirstName: | HARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3104715852 | ||||||||
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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 | 208600000X | G57467 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208200000X | G57467 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00G574670 | 05 | CA | MEDICAID |