Provider Demographics
NPI:1255362687
Name:PROFESSIONAL ORTHOPEDICS MEDICAL ASSOCIATES A PROF MEDICAL CORP
Entity type:Organization
Organization Name:PROFESSIONAL ORTHOPEDICS MEDICAL ASSOCIATES A PROF MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-888-2855
Mailing Address - Street 1:7345 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE #280
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1937
Mailing Address - Country:US
Mailing Address - Phone:818-888-2855
Mailing Address - Fax:818-888-0702
Practice Address - Street 1:7345 MEDICAL CENTER DR
Practice Address - Street 2:SUITE #280
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1937
Practice Address - Country:US
Practice Address - Phone:818-888-2855
Practice Address - Fax:818-888-0702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 16970363A00000X
CAPT24912225100000X
CAA79561207X00000X
CAE3859213ES0103X
CAG065065207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ53604Z22OtherBS GROUP
ZZZ53604Z22OtherBS GROUP
CAQ07077Medicare UPIN
CAU37026Medicare UPIN
CA1104410001Medicare NSC
CAW10980Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
CAWA7356BMedicare PIN
CAE17558Medicare UPIN
=========OtherEIN
CAH45278Medicare UPIN