Provider Demographics
NPI:1821332503
Name:INNOVATIVE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:INNOVATIVE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HRAK
Authorized Official - Middle Name:
Authorized Official - Last Name:DERDERIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-558-3777
Mailing Address - Street 1:372 E OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1215
Mailing Address - Country:US
Mailing Address - Phone:818-558-3777
Mailing Address - Fax:818-558-3778
Practice Address - Street 1:372 E OLIVE AVE
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1215
Practice Address - Country:US
Practice Address - Phone:818-558-3777
Practice Address - Fax:818-558-3778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-19
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92365207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92365Medicaid
CACV083YMedicare PIN