Provider Demographics
NPI:1962659151
Name:BENJAMIN BROUKHIM M.D. A MEDICAL CORP
Entity Type:Organization
Organization Name:BENJAMIN BROUKHIM M.D. A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUKHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-755-6070
Mailing Address - Street 1:11650 RIVERSIDE DR
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91602-1093
Mailing Address - Country:US
Mailing Address - Phone:818-755-6070
Mailing Address - Fax:818-755-1870
Practice Address - Street 1:11650 RIVERSIDE DR
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91602-1093
Practice Address - Country:US
Practice Address - Phone:818-755-6070
Practice Address - Fax:818-755-1870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37198207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A37198Medicaid
CA00A37198Medicaid