Provider Demographics
NPI:1053493056
Name:GLENWEST MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:GLENWEST MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEVORK
Authorized Official - Middle Name:
Authorized Official - Last Name:MAISSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:818-243-1186
Mailing Address - Street 1:1737 W GLENOAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-1542
Mailing Address - Country:US
Mailing Address - Phone:818-243-1186
Mailing Address - Fax:818-243-3868
Practice Address - Street 1:1737 W GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-1542
Practice Address - Country:US
Practice Address - Phone:818-243-1186
Practice Address - Fax:818-243-3868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10524207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W15835Medicare PIN