Provider Demographics
NPI:1881642288
Name:DOHENY ENDOSURGICAL CENTER INC
Entity Type:Organization
Organization Name:DOHENY ENDOSURGICAL CENTER INC
Other - Org Name:DOHENY ENDOSURGICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-550-0400
Mailing Address - Street 1:9090 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1848
Mailing Address - Country:US
Mailing Address - Phone:310-246-2555
Mailing Address - Fax:310-285-0819
Practice Address - Street 1:9090 WILSHIRE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1848
Practice Address - Country:US
Practice Address - Phone:310-246-2555
Practice Address - Fax:310-285-0819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69377261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS051751Medicare UPIN
CA05C0001751Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER