Provider Demographics
NPI:1386865798
Name:JEREMY E KORMAN MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JEREMY E KORMAN MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:NAPORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-325-4415
Mailing Address - Street 1:4644 LINCOLN BLVD
Mailing Address - Street 2:STE 450
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6374
Mailing Address - Country:US
Mailing Address - Phone:310-577-5540
Mailing Address - Fax:310-577-5616
Practice Address - Street 1:4644 LINCOLN BLVD
Practice Address - Street 2:STE 450
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6374
Practice Address - Country:US
Practice Address - Phone:310-577-5540
Practice Address - Fax:310-577-5616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208600000X
CAG83221208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G46936Medicare UPIN
CAG83221Medicare ID - Type Unspecified