Provider Demographics
NPI:1184938623
Name:PAUL H ACKERMAN M D INC
Entity type:Organization
Organization Name:PAUL H ACKERMAN M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:H
Authorized Official - Last Name:ACKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-826-4882
Mailing Address - Street 1:11980 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 621
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5012
Mailing Address - Country:US
Mailing Address - Phone:310-826-4882
Mailing Address - Fax:310-476-5819
Practice Address - Street 1:11980 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 621
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5012
Practice Address - Country:US
Practice Address - Phone:310-826-4882
Practice Address - Fax:310-476-5819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-26
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG11839261QM0850X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA90165Medicare UPIN
CAG11839Medicare PIN