Basic Information
| Provider Information | |||||||||
| NPI: | 1689629057 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEDAN | ||||||||
| FirstName: | ILAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N ROBERTSON BLVD | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103853496 | ||||||||
| FaxNumber: | 3102479614 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 N ROBERTSON BLVD | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103853496 | ||||||||
| FaxNumber: | 3102479614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 04/01/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MD034206 | DC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 174400000X | A93684 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 035716400 | 05 | DC | MEDICAID | 404855500 | 05 | MD | MEDICAID |