Provider Demographics
NPI:1245265750
Name:SAMY FARAG, M.D. MEDICAL GROUP, MC
Entity type:Organization
Organization Name:SAMY FARAG, M.D. MEDICAL GROUP, MC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMY
Authorized Official - Middle Name:S
Authorized Official - Last Name:FARAG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-665-5600
Mailing Address - Street 1:PO BOX 781
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91012-0781
Mailing Address - Country:US
Mailing Address - Phone:323-665-5600
Mailing Address - Fax:323-665-8500
Practice Address - Street 1:4430 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-2014
Practice Address - Country:US
Practice Address - Phone:323-665-5600
Practice Address - Fax:323-665-8500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25821261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W19606Medicare ID - Type Unspecified
A83289Medicare UPIN