Provider Demographics
NPI:1417248840
Name:CHAMPION MEDICAL GROUP, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CHAMPION MEDICAL GROUP, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-474-9809
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:888-431-8819
Practice Address - Street 1:8121 VAN NUYS BLVD
Practice Address - Street 2:STE 316
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-5105
Practice Address - Country:US
Practice Address - Phone:818-994-1102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHAMPION MEDICAL GROUP, A MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-19
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site