Provider Demographics
NPI:1639400260
Name:ASSUTA FAMILY MEDICAL GROUP A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ASSUTA FAMILY MEDICAL GROUP A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SOROUSH
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:RAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-760-2800
Mailing Address - Street 1:12922 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-2924
Mailing Address - Country:US
Mailing Address - Phone:818-760-2800
Mailing Address - Fax:818-760-7343
Practice Address - Street 1:12922 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-2924
Practice Address - Country:US
Practice Address - Phone:818-760-2800
Practice Address - Fax:818-760-7343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82603207Q00000X
CAA33650207R00000X
CAA41783207V00000X
CAA42806208000000X
CAA602942086X0206X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty