Basic Information
| Provider Information | |||||||||
| NPI: | 1669670212 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY CHILDRENS MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6430 W SUNSET BLVD | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900287901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233612337 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4650 W SUNSET BLVD | ||||||||
| Address2: | MS#12 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233612557 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 10/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | SADAMITSU | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3233612109 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR006667B | 01 | CA | MEDICAID | OTHER |