Provider Demographics
NPI:1508904731
Name:MEDICAL CLINIC AND SURGICAL SPECIALTIES OF GLENDALE
Entity Type:Organization
Organization Name:MEDICAL CLINIC AND SURGICAL SPECIALTIES OF GLENDALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MARDIROS
Authorized Official - Middle Name:HAIG
Authorized Official - Last Name:MIHRANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-240-1820
Mailing Address - Street 1:1510 S CENTRAL AVE
Mailing Address - Street 2:#100
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2582
Mailing Address - Country:US
Mailing Address - Phone:818-240-1820
Mailing Address - Fax:818-240-1021
Practice Address - Street 1:1510 S CENTRAL AVE
Practice Address - Street 2:#100
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2582
Practice Address - Country:US
Practice Address - Phone:818-240-1820
Practice Address - Fax:818-240-1021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30059208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A300590Medicaid
CA00A300590Medicaid
A84038Medicare UPIN