Provider Demographics
NPI:1801851043
Name:FAMILY PRACTICE OF GLENDALE A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:FAMILY PRACTICE OF GLENDALE A MEDICAL CORPORATION
Other - Org Name:FAMILY MEDICINE CENTER AND DESCANSO FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR/ OFFICER/A.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:SIRVARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANOYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-445-7143
Mailing Address - Street 1:1125 E BROADWAY
Mailing Address - Street 2:BOX 71
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1315
Mailing Address - Country:US
Mailing Address - Phone:818-500-5586
Mailing Address - Fax:818-500-5583
Practice Address - Street 1:801 S CHEVY CHASE DR STE 230
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-4436
Practice Address - Country:US
Practice Address - Phone:818-500-5586
Practice Address - Fax:818-500-5587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0044711Medicaid
CAGR0044710Medicaid
CAGR0044711Medicaid
CAGR0044710Medicaid