Provider Demographics
NPI:1538100094
Name:PACIFIC MULTI SPECIALTY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PACIFIC MULTI SPECIALTY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VAHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MADATOVIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-241-9100
Mailing Address - Street 1:127 S BRAND BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1342
Mailing Address - Country:US
Mailing Address - Phone:818-241-9100
Mailing Address - Fax:818-551-9634
Practice Address - Street 1:127 S BRAND BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1342
Practice Address - Country:US
Practice Address - Phone:818-241-9100
Practice Address - Fax:818-551-9634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54463170100000X
CAA53748170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Multi-Specialty