Provider Demographics
NPI:1760525752
Name:FOOTHILL SURGICAL SPECIALISTS MEDICAL GROUP
Entity Type:Organization
Organization Name:FOOTHILL SURGICAL SPECIALISTS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MD
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:CARVAJAL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:818-243-1135
Mailing Address - Street 1:1560 E. CHEVY CHASE DR.
Mailing Address - Street 2:SUITE 430
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4197
Mailing Address - Country:US
Mailing Address - Phone:818-243-1135
Mailing Address - Fax:818-243-9332
Practice Address - Street 1:1560 E. CHEVY CHASE DR.
Practice Address - Street 2:SUITE 430
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4197
Practice Address - Country:US
Practice Address - Phone:818-243-1135
Practice Address - Fax:818-243-9332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty