Provider Demographics
NPI:1790705267
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:323-725-6933
Practice Address - Street 1:5504 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-4104
Practice Address - Country:US
Practice Address - Phone:323-725-0167
Practice Address - Fax:323-725-6933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41061207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0020630Medicaid
CAW9296Medicare PIN