Provider Demographics
NPI:1689717498
Name:RWSUDA-ASHURWITZ MEDICAL CORP
Entity Type:Organization
Organization Name:RWSUDA-ASHURWITZ MEDICAL CORP
Other - Org Name:RWSUDA-ASHURWITZ MEDICAL CORP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:JAYE
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-244-4374
Mailing Address - Street 1:1510 S CENTRAL AVE
Mailing Address - Street 2:SUITE 530
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2500
Mailing Address - Country:US
Mailing Address - Phone:818-244-4374
Mailing Address - Fax:818-244-0633
Practice Address - Street 1:1510 S CENTRAL AVE
Practice Address - Street 2:SUITE 530
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2500
Practice Address - Country:US
Practice Address - Phone:818-244-4374
Practice Address - Fax:818-244-0633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53084174400000X
CAG75481174400000X
CAA60385174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE89868Medicare ID - Type Unspecified
I12156Medicare ID - Type Unspecified
CAG32886Medicare ID - Type Unspecified