Provider Demographics
NPI:1437551033
Name:BOULEVARD MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BOULEVARD MEDICAL GROUP, INC.
Other - Org Name:PROHEALTH PHYSICAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:818-505-0152
Mailing Address - Street 1:11239 VENTURA BLVD STE 213
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-3167
Mailing Address - Country:US
Mailing Address - Phone:818-505-0152
Mailing Address - Fax:818-505-0398
Practice Address - Street 1:11239 VENTURA BLVD STE 213
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-3167
Practice Address - Country:US
Practice Address - Phone:818-505-0152
Practice Address - Fax:818-505-0398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208100000X
CA28487111N00000X
CAA89000207PE0004X
CA51653363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB236695OtherMEDICARE DME PTAN