Provider Demographics
NPI:1629132535
Name:CARDIOLOGY PRACTICE MEDICAL GROUP
Entity Type:Organization
Organization Name:CARDIOLOGY PRACTICE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:FERNANDO
Authorized Official - Last Name:PEGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-365-9595
Mailing Address - Street 1:17075 DEVONSHIRE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-5407
Mailing Address - Country:US
Mailing Address - Phone:818-365-9595
Mailing Address - Fax:818-365-8955
Practice Address - Street 1:17075 DEVONSHIRE ST STE 201
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-5407
Practice Address - Country:US
Practice Address - Phone:818-365-9595
Practice Address - Fax:818-365-8955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33230174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA222031992OtherBLUE SHIELD
CA060067979OtherMEDICARE RAILROAD
CAGR0091580Medicaid
CAW15511Medicare PIN
CA060067979OtherMEDICARE RAILROAD