Provider Demographics
NPI:1265572903
Name:BROOKDALE MEDICAL CENTER INC
Entity type:Organization
Organization Name:BROOKDALE MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARKODAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-567-9909
Mailing Address - Street 1:2809 TWEEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280
Mailing Address - Country:US
Mailing Address - Phone:323-567-9909
Mailing Address - Fax:323-567-9929
Practice Address - Street 1:2809 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280
Practice Address - Country:US
Practice Address - Phone:323-567-9909
Practice Address - Fax:323-567-9929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOA44541208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102030Medicaid