Provider Demographics
NPI:1659597458
Name:YASER A SLAYYEH M D F A C C A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:YASER A SLAYYEH M D F A C C A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YASER
Authorized Official - Middle Name:A
Authorized Official - Last Name:SLAYYEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-882-3300
Mailing Address - Street 1:399 E HIGHLAND AVE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3808
Mailing Address - Country:US
Mailing Address - Phone:909-882-3300
Mailing Address - Fax:909-882-3512
Practice Address - Street 1:399 E HIGHLAND AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3808
Practice Address - Country:US
Practice Address - Phone:909-882-3300
Practice Address - Fax:909-882-3512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56032174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA56032OtherSTATE LICENSE
CADB9077OtherRR MEDICARE GRP ID
CA00A560320Medicaid
CA00A560320Medicaid
CA=========OtherEIN
CAF14240Medicare UPIN