Provider Demographics
NPI:1386829034
Name:UNIVERSITY CHILDRENS MEDICAL GROUP
Entity Type:Organization
Organization Name:UNIVERSITY CHILDRENS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SADAMITSU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-361-2345
Mailing Address - Street 1:6430 W SUNSET BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4650 W SUNSET BLVD # 114
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-2289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0066679Medicaid