Provider Demographics
NPI:1285642033
Name:NORTHRIDGE FAMILY PRACTICE MEDICAL GROUP
Entity Type:Organization
Organization Name:NORTHRIDGE FAMILY PRACTICE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-885-5480
Mailing Address - Street 1:18406 ROSCOE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325
Mailing Address - Country:US
Mailing Address - Phone:818-885-5480
Mailing Address - Fax:818-885-5430
Practice Address - Street 1:18406 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325
Practice Address - Country:US
Practice Address - Phone:818-885-5480
Practice Address - Fax:818-885-5430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W1896Medicare PIN