Provider Demographics
NPI:1225047723
Name:CEDARS NORTHWEST MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:CEDARS NORTHWEST MEDICAL GROUP, INC.
Other - Org Name:CEDAR NORTHWEST DIAGNOSTIC MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-791-0953
Mailing Address - Street 1:1403 N FAIR OAKS AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1858
Mailing Address - Country:US
Mailing Address - Phone:626-791-0953
Mailing Address - Fax:
Practice Address - Street 1:1403 N FAIR OAKS AVE
Practice Address - Street 2:STE 2
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1858
Practice Address - Country:US
Practice Address - Phone:626-791-0953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC2775917OtherCORPORATION NUMBER
CAW13909Medicare ID - Type UnspecifiedDR. BOUTROS' MEDICARE #