Provider Demographics
NPI:1578017778
Name:MESA ADVANTAGE MEDICAL GROUP
Entity Type:Organization
Organization Name:MESA ADVANTAGE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LAN
Authorized Official - Middle Name:NHU BICH
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-399-8996
Mailing Address - Street 1:2295 HUNTINGTON DR # D
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2640
Mailing Address - Country:US
Mailing Address - Phone:626-656-2370
Mailing Address - Fax:626-248-9060
Practice Address - Street 1:2295 HUNTINGTON DR # D
Practice Address - Street 2:
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-2640
Practice Address - Country:US
Practice Address - Phone:626-656-2370
Practice Address - Fax:626-248-9060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
302F00000X
CAA302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization