Provider Demographics
NPI:1487820601
Name:ROBERT A. AUDELL, M.D.,MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ROBERT A. AUDELL, M.D.,MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WODIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-432-1401
Mailing Address - Street 1:8670 WILSHIRE BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2930
Mailing Address - Country:US
Mailing Address - Phone:310-855-0751
Mailing Address - Fax:310-657-6342
Practice Address - Street 1:8670 WILSHIRE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2930
Practice Address - Country:US
Practice Address - Phone:310-855-0751
Practice Address - Fax:310-657-6342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG047826261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG47826Medicare PIN
CA6027200001Medicare NSC