Basic Information
| Provider Information | |||||||||
| NPI: | 1730126103 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEUROVASCULAR MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 23407 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911850001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153531863 | ||||||||
| FaxNumber: | 4153538606 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 PARNASSUS AVE | ||||||||
| Address2: | L352 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941432204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153531863 | ||||||||
| FaxNumber: | 4153538606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 05/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | HIGASHIDA | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4153531863 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0026390 | 05 | CA | MEDICAID |