Provider Demographics
NPI:1942334958
Name:ST. MICHAEL'S NEUROLOGY MEDICAL CORP
Entity Type:Organization
Organization Name:ST. MICHAEL'S NEUROLOGY MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERIF
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIMYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:310-225-5599
Mailing Address - Street 1:1141 W REDONDO BEACH BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-3586
Mailing Address - Country:US
Mailing Address - Phone:310-225-5599
Mailing Address - Fax:310-225-5660
Practice Address - Street 1:1141 W REDONDO BEACH BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3586
Practice Address - Country:US
Practice Address - Phone:310-225-5599
Practice Address - Fax:310-225-5660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6410204D00000X, 2084N0600X, 2084P2900X, 2084S0012X, 2084V0102X
CA20A61402084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Single Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Single Specialty
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep MedicineGroup - Single Specialty
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX6461Medicaid
CA20A6410OtherMEDICAL LICENSE
CAF76511Medicare UPIN
CA20A6410OtherMEDICAL LICENSE