Provider Demographics
NPI:1013102854
Name:GLENDALE COMMUNITY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:GLENDALE COMMUNITY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DUC
Authorized Official - Middle Name:C
Authorized Official - Last Name:BUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-265-2203
Mailing Address - Street 1:801 S CHEVY CHASE DR
Mailing Address - Street 2:105
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-4431
Mailing Address - Country:US
Mailing Address - Phone:818-265-2203
Mailing Address - Fax:818-265-2201
Practice Address - Street 1:801 S CHEVY CHASE DR
Practice Address - Street 2:105
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-4431
Practice Address - Country:US
Practice Address - Phone:818-265-2203
Practice Address - Fax:818-265-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45958174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A459580Medicaid
CA00A459580Medicaid
CAW15716Medicare PIN