Provider Demographics
NPI:1023871779
Name:MGM PHYSICIAN ASSISTANT INC
Entity type:Organization
Organization Name:MGM PHYSICIAN ASSISTANT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:HABEEB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-810-6554
Mailing Address - Street 1:3400 BAHIA PL
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-4023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:609 DEEP VALLEY DR STE 200
Practice Address - Street 2:
Practice Address - City:ROLLING HILLS ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-3614
Practice Address - Country:US
Practice Address - Phone:310-810-6554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty