Provider Demographics
NPI:1134274418
Name:PRIMARY CARE SPORTS MEDICINE A MEDICAL CORPORATION
Entity type:Organization
Organization Name:PRIMARY CARE SPORTS MEDICINE A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-501-7276
Mailing Address - Street 1:18411 CLARK ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3506
Mailing Address - Country:US
Mailing Address - Phone:818-501-7276
Mailing Address - Fax:818-501-7288
Practice Address - Street 1:18411 CLARK ST STE 302
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3541
Practice Address - Country:US
Practice Address - Phone:818-501-7276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62510208000000X, 2080S0010X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G69035Medicare UPIN