Provider Demographics
NPI:1790094639
Name:RONALD A CARLISH MEDICAL GROUP
Entity Type:Organization
Organization Name:RONALD A CARLISH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARLISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-977-9421
Mailing Address - Street 1:1127 WILSHIRE BLVD
Mailing Address - Street 2:STE 820
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-3910
Mailing Address - Country:US
Mailing Address - Phone:213-977-9421
Mailing Address - Fax:213-977-9422
Practice Address - Street 1:1127 WILSHIRE BLVD
Practice Address - Street 2:STE 820
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-3910
Practice Address - Country:US
Practice Address - Phone:213-977-9421
Practice Address - Fax:213-977-9422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG15424207RC0000X, 2081P2900X
CAA642442084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG15424OtherSTATE LICENSE
CAEH401AMedicare PIN