Basic Information
| Provider Information | |||||||||
| NPI: | 1902444623 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SKILLED PHYSICIANS GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12021 WILSHIRE BLVD # 745 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900251206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104455999 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3747 FOOTHILL BLVD # B140 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912141700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104455999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2019 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
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| AuthorizedOfficialLastName: | ANVAR | ||||||||
| AuthorizedOfficialFirstName: | BARDIA | ||||||||
| AuthorizedOfficialMiddleName: | AARON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3104455999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.