Provider Demographics
NPI:1417495904
Name:ELECTRO DIAGNOSTIC MEDICINE
Entity Type:Organization
Organization Name:ELECTRO DIAGNOSTIC MEDICINE
Other - Org Name:EMG&NCV PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALIASGHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MATIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-308-7450
Mailing Address - Street 1:1407 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-2416
Mailing Address - Country:US
Mailing Address - Phone:818-547-9870
Mailing Address - Fax:
Practice Address - Street 1:5635 CAHUENGA BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-2104
Practice Address - Country:US
Practice Address - Phone:818-308-7450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOTAL REHABILITATION MEDICINE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97751204R00000X, 2081N0008X, 2081P2900X, 291U00000X
CAPT12456261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Single Specialty
No2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular MedicineGroup - Single Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1679730923Medicaid