Provider Demographics
NPI:1932513298
Name:MMI MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MMI MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARSHAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-954-9483
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-943-4180
Mailing Address - Fax:888-431-8819
Practice Address - Street 1:8670 WILSHIRE BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2924
Practice Address - Country:US
Practice Address - Phone:310-954-9483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MMI MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-16
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78454332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site