Provider Demographics
NPI:1326622143
Name:BEVERLY MEDICAL GROUP
Entity Type:Organization
Organization Name:BEVERLY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:N
Authorized Official - Last Name:DZEBOLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:132-771-0302
Mailing Address - Street 1:2105 BEVERLY BLVD STE 233B
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2216
Mailing Address - Country:US
Mailing Address - Phone:213-674-7859
Mailing Address - Fax:213-674-7863
Practice Address - Street 1:2105 BEVERLY BLVD STE 233B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2216
Practice Address - Country:US
Practice Address - Phone:213-674-7859
Practice Address - Fax:213-277-1055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-07
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center