Basic Information
| Provider Information | |||||||||
| NPI: | 1790712131 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMI/HTI TARZANA ENCINO JOINT VENTURE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ENCINO-TARZANA REGIONAL MEDICAL CTR-ENCINO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31001-0152 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911101526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263004122 | ||||||||
| FaxNumber: | 8189078630 | ||||||||
| Practice Location | |||||||||
| Address1: | 16237 VENTURA BLVD | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914362201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188810800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RABE | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF TAXATION, TENET HEALTHCARE | ||||||||
| AuthorizedOfficialTelephone: | 4698932530 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 930000051 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | ZZZA1953Z | 01 | BS OF CALIFORNIA | OTHER | 050158B000000 | 01 | SECTION 1011 | OTHER | HSC31408I | 05 | CA | MEDICAID | HSP40158L | 05 | CA | MEDICAID | HSP30158L | 05 | CA | MEDICAID |