Provider Demographics
NPI:1629273818
Name:TOWER ORTHOPAEDICS AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:TOWER ORTHOPAEDICS AND SPORTS MEDICINE
Other - Org Name:TOWER ORTHOPAEDICS
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GANJIANPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-855-0751
Mailing Address - Street 1:6330 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5425
Mailing Address - Country:US
Mailing Address - Phone:310-855-0751
Mailing Address - Fax:310-358-2457
Practice Address - Street 1:6330 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5425
Practice Address - Country:US
Practice Address - Phone:310-855-0751
Practice Address - Fax:310-358-2457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14528Medicare ID - Type Unspecified