Provider Demographics
NPI:1497807184
Name:PEDIATRIC GASTROENTEROLOGY MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:PEDIATRIC GASTROENTEROLOGY MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAIED
Authorized Official - Middle Name:
Authorized Official - Last Name:DALLALZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-986-0006
Mailing Address - Street 1:16661 VENTURA BLVD STE 718
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1995
Mailing Address - Country:US
Mailing Address - Phone:818-986-0006
Mailing Address - Fax:818-986-2333
Practice Address - Street 1:16661 VENTURA BLVD
Practice Address - Street 2:SUITE 613
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1914
Practice Address - Country:US
Practice Address - Phone:818-986-0006
Practice Address - Fax:818-986-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00300204261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A489420Medicaid