Provider Demographics
NPI:1245367051
Name:STEVEN G KHWARG M D PROF CORP
Entity type:Organization
Organization Name:STEVEN G KHWARG M D PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUMMETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-345-6879
Mailing Address - Street 1:201 S ALVARADO ST
Mailing Address - Street 2:SUITE 718
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2320
Mailing Address - Country:US
Mailing Address - Phone:213-483-0150
Mailing Address - Fax:213-484-1417
Practice Address - Street 1:201 S ALVARADO ST
Practice Address - Street 2:SUITE 718
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2320
Practice Address - Country:US
Practice Address - Phone:213-483-0150
Practice Address - Fax:213-484-1417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930000943261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01075FMedicaid
CASUR01075FMedicaid
CAS551075AMedicare ID - Type UnspecifiedPROVIDER NUMBER