Basic Information
| Provider Information | |||||||||
| NPI: | 1750491247 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIME HEALTHCARE SERVICES - SHERMAN OAKS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHERMAN OAKS HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 E GUASTI RD | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917618655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092354400 | ||||||||
| FaxNumber: | 9092354419 | ||||||||
| Practice Location | |||||||||
| Address1: | 4929 VAN NUYS BLVD. | ||||||||
| Address2: | |||||||||
| City: | SHERMAN OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914031702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189817111 | ||||||||
| FaxNumber: | 8185016430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 01/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | REDDY | ||||||||
| AuthorizedOfficialFirstName: | PREM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHAIRMAN/PRES/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9092354400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD, FACC, FCCP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 930000149 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSP301141 | 05 | CA | MEDICAID | HSP30114I | 05 | CA | MEDICAID | HSP401141 | 05 | CA | MEDICAID | ZZZA1966Z | 01 | CA | BLUE SHIELD | OTHER | HSC30114I | 05 | CA | MEDICAID | HSC301141 | 05 | CA | MEDICAID | HSP40114I | 05 | CA | MEDICAID |