Provider Demographics
NPI:1710160635
Name:SOUTH ATLANTIC MEDICAL GROUP
Entity Type:Organization
Organization Name:SOUTH ATLANTIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NISSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-725-0167
Mailing Address - Street 1:5504 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-4104
Mailing Address - Country:US
Mailing Address - Phone:323-725-0167
Mailing Address - Fax:
Practice Address - Street 1:6300 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:BELL GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90201-8900
Practice Address - Country:US
Practice Address - Phone:562-806-6667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41061208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0020633Medicaid