Provider Demographics
NPI: | 1801184841 |
---|---|
Name: | MAYWOOD FAMILY MEDICAL CENTER |
Entity Type: | Organization |
Organization Name: | MAYWOOD FAMILY MEDICAL CENTER |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CHIEF EXECUTIVE OFFICER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | RAGAA |
Authorized Official - Middle Name: | Z |
Authorized Official - Last Name: | ISKAROUS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 562-522-7413 |
Mailing Address - Street 1: | 5920 ATLANTIC BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | MAYWOOD |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90270-3101 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 323-562-2535 |
Mailing Address - Fax: | 323-562-2558 |
Practice Address - Street 1: | 5920 ATLANTIC BLVD |
Practice Address - Street 2: | |
Practice Address - City: | MAYWOOD |
Practice Address - State: | CA |
Practice Address - Zip Code: | 90270-3101 |
Practice Address - Country: | US |
Practice Address - Phone: | 323-562-2535 |
Practice Address - Fax: | 323-562-2558 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-07-12 |
Last Update Date: | 2011-07-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | A45155 | 261Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center |