Provider Demographics
NPI:1962683268
Name:PORTER RANCH PSYCHIATRIC MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PORTER RANCH PSYCHIATRIC MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-527-1288
Mailing Address - Street 1:PO BOX 7008
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91327-7008
Mailing Address - Country:US
Mailing Address - Phone:818-527-1288
Mailing Address - Fax:818-428-3237
Practice Address - Street 1:18250 ROSCOE BLVD STE 245
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4248
Practice Address - Country:US
Practice Address - Phone:818-527-1288
Practice Address - Fax:818-812-9025
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORTER RANCH PSYCHIATRIC MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-15
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A322501Medicaid
CAW17833Medicare PIN
CA00A322501Medicaid