Provider Demographics
NPI:1508804006
Name:IMD MEDICAL GROUP INC
Entity Type:Organization
Organization Name:IMD MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:EL ASMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-487-6867
Mailing Address - Street 1:1234 N VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-1704
Mailing Address - Country:US
Mailing Address - Phone:213-487-6867
Mailing Address - Fax:213-487-6811
Practice Address - Street 1:1234 N VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1704
Practice Address - Country:US
Practice Address - Phone:213-487-6867
Practice Address - Fax:213-487-6811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61923261QP2300X
CAA89382261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0093890Medicaid
CAW16075Medicare PIN
CAGR0093890Medicaid