Provider Demographics
NPI:1538331848
Name:GREGG SMALL MEDICAL CORP
Entity Type:Organization
Organization Name:GREGG SMALL MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-907-7828
Mailing Address - Street 1:15720 VENTURA BLVD
Mailing Address - Street 2:SUITE 227
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15720 VENTURA BLVD
Practice Address - Street 2:SUITE 227
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2914
Practice Address - Country:US
Practice Address - Phone:818-907-7828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70119208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19163Medicare PIN