Provider Demographics
NPI:1417445487
Name:CORE GERIATRIC MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:CORE GERIATRIC MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:AYVAZYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSPA-C
Authorized Official - Phone:818-723-8804
Mailing Address - Street 1:1505 S GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-3315
Mailing Address - Country:US
Mailing Address - Phone:818-758-9588
Mailing Address - Fax:818-975-5217
Practice Address - Street 1:1505 S GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-3315
Practice Address - Country:US
Practice Address - Phone:818-758-9588
Practice Address - Fax:818-975-5217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty