Provider Demographics
NPI:1003824434
Name:NORTHRIDGE FACIAL PLASTIC SURGERY MEDICAL GROUP A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:NORTHRIDGE FACIAL PLASTIC SURGERY MEDICAL GROUP A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:M
Authorized Official - Last Name:KERNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-349-0600
Mailing Address - Street 1:18350 ROSCOE BLVD # 318A
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-4109
Mailing Address - Country:US
Mailing Address - Phone:818-993-9824
Mailing Address - Fax:818-993-0937
Practice Address - Street 1:18350 ROSCOE BLVD
Practice Address - Street 2:#318A
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4109
Practice Address - Country:US
Practice Address - Phone:818-993-9824
Practice Address - Fax:818-993-0937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAS051366261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZH1907BOtherBLUE SHIELD PROV IDENTICA
CASO51366OtherMEDICARE
CASO51366OtherMEDICARE
CAS051366Medicare PIN