Provider Demographics
NPI:1588028625
Name:SHERMAN OAKS INTEGRATED MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:SHERMAN OAKS INTEGRATED MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MINORITY OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-786-5985
Mailing Address - Street 1:4835 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2109
Mailing Address - Country:US
Mailing Address - Phone:818-786-5985
Mailing Address - Fax:818-786-6849
Practice Address - Street 1:4835 VAN NUYS BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2109
Practice Address - Country:US
Practice Address - Phone:818-786-5985
Practice Address - Fax:818-786-6849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
CAA102275208100000X
CA20A116332081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7585010001Medicare NSC