Provider Demographics
NPI:1972683555
Name:NORTHRIDGE PAIN MANAGEMENT SPECIALISTS MEDICAL CORPORATION
Entity Type:Organization
Organization Name:NORTHRIDGE PAIN MANAGEMENT SPECIALISTS MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:IMAD
Authorized Official - Middle Name:H
Authorized Official - Last Name:RASOOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PHD
Authorized Official - Phone:818-993-3428
Mailing Address - Street 1:PO BOX 33278
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91394-3278
Mailing Address - Country:US
Mailing Address - Phone:818-993-3428
Mailing Address - Fax:818-993-3469
Practice Address - Street 1:8331 RESEDA BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-4620
Practice Address - Country:US
Practice Address - Phone:818-993-3428
Practice Address - Fax:818-993-3469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14351Medicare ID - Type UnspecifiedPROVIDER NUMBER