Provider Demographics
NPI:1174740880
Name:MEDNIK MEDICAL CORPORATION
Entity type:Organization
Organization Name:MEDNIK MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDNIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PH D
Authorized Official - Phone:310-492-0613
Mailing Address - Street 1:369 S DOHENY DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-3508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8501 WILSHIRE BLVD
Practice Address - Street 2:STE 250
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-3101
Practice Address - Country:US
Practice Address - Phone:310-492-0613
Practice Address - Fax:310-289-0372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52346261QR0200X, 261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Not Answered261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A523461Medicaid
CAG13477Medicare UPIN
CAA52346BMedicare ID - Type Unspecified