Provider Demographics
NPI:1720554041
Name:MGB MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MGB MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:REPIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-962-5505
Mailing Address - Street 1:7535 LAUREL CANYON BLVD
Mailing Address - Street 2:
Mailing Address - City:N HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605-3149
Mailing Address - Country:US
Mailing Address - Phone:818-962-5505
Mailing Address - Fax:
Practice Address - Street 1:7535 LAUREL CANYON BLVD
Practice Address - Street 2:
Practice Address - City:N HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-3149
Practice Address - Country:US
Practice Address - Phone:818-962-5505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-15
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty