Provider Demographics
NPI:1639152820
Name:CHILDRENS CARDIAC MEDICAL CLINIC
Entity Type:Organization
Organization Name:CHILDRENS CARDIAC MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:L
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-445-5552
Mailing Address - Street 1:301 W HUNTINGTON DR
Mailing Address - Street 2:#415
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-3462
Mailing Address - Country:US
Mailing Address - Phone:626-445-5552
Mailing Address - Fax:626-445-4411
Practice Address - Street 1:301 W HUNTINGTON DR
Practice Address - Street 2:#415
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-3462
Practice Address - Country:US
Practice Address - Phone:626-445-5552
Practice Address - Fax:626-445-4411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG124582080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G124580Medicaid
CA00G124580Medicaid
CAG12458Medicare ID - Type Unspecified