Provider Demographics
NPI:1770822645
Name:HYDE PARK MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:HYDE PARK MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAHIL
Authorized Official - Middle Name:RASHID
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-877-5692
Mailing Address - Street 1:6011 PACIFIC BLVD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-2951
Mailing Address - Country:US
Mailing Address - Phone:714-568-1100
Mailing Address - Fax:714-568-1101
Practice Address - Street 1:13950 MILTON AVE
Practice Address - Street 2:SUITE 404
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-2900
Practice Address - Country:US
Practice Address - Phone:714-568-1100
Practice Address - Fax:714-568-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA623622081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH77576Medicare UPIN