Provider Demographics
NPI:1922013515
Name:PACIFIC NEPHROLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:PACIFIC NEPHROLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DYLAN
Authorized Official - Last Name:HEALY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-674-8600
Mailing Address - Street 1:323 N PRAIRIE AVE # 334
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4502
Mailing Address - Country:US
Mailing Address - Phone:310-674-8600
Mailing Address - Fax:310-671-9883
Practice Address - Street 1:323 N PRAIRIE AVE # 334
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4502
Practice Address - Country:US
Practice Address - Phone:310-674-8600
Practice Address - Fax:310-671-9883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0000360Medicaid
CAW5961AMedicare ID - Type Unspecified