Provider Demographics
NPI:1093752677
Name:GLENDALE PODIATRY GROUP
Entity Type:Organization
Organization Name:GLENDALE PODIATRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HERSCHEL
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:ROSENBLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-240-5575
Mailing Address - Street 1:800 S CENTRAL AVE
Mailing Address - Street 2:#302
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-4370
Mailing Address - Country:US
Mailing Address - Phone:818-240-5575
Mailing Address - Fax:818-240-1487
Practice Address - Street 1:800 S CENTRAL AVE
Practice Address - Street 2:#302
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-4370
Practice Address - Country:US
Practice Address - Phone:818-240-5575
Practice Address - Fax:818-240-1487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1114213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0352060001Medicare NSC