Provider Demographics
NPI:1942571047
Name:WASHINGTON MEDICAL GROUP
Entity Type:Organization
Organization Name:WASHINGTON MEDICAL GROUP
Other - Org Name:WASHINGTON HEALTHCARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANVELYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-398-4069
Mailing Address - Street 1:2544 E WASHINGTON BLVD
Mailing Address - Street 2:STE C
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1452
Mailing Address - Country:US
Mailing Address - Phone:626-398-4069
Mailing Address - Fax:626-798-9041
Practice Address - Street 1:2544 E WASHINGTON BLVD
Practice Address - Street 2:STE C
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1452
Practice Address - Country:US
Practice Address - Phone:626-398-4069
Practice Address - Fax:626-798-9041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55018174400000X
CAE3953213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty