Provider Demographics
NPI:1487689238
Name:MINIMALLY INVASIVE SURGICAL TEAM INC
Entity Type:Organization
Organization Name:MINIMALLY INVASIVE SURGICAL TEAM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:KEVORK
Authorized Official - Last Name:TASHJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-265-2260
Mailing Address - Street 1:801 SOUTH CHEVY CHASE DRIVE
Mailing Address - Street 2:101
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205
Mailing Address - Country:US
Mailing Address - Phone:818-265-2260
Mailing Address - Fax:818-265-2268
Practice Address - Street 1:801 SOUTH CHEVY CHASE DRIVE
Practice Address - Street 2:101
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205
Practice Address - Country:US
Practice Address - Phone:818-265-2260
Practice Address - Fax:818-265-2268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81027208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A810270Medicaid
CA00A810270Medicaid
CAI24674Medicare UPIN