Provider Demographics
NPI:1336365576
Name:COLUMBIA MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:COLUMBIA MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HOVIK
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMITYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-664-4114
Mailing Address - Street 1:1211 N VERMONT AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-1748
Mailing Address - Country:US
Mailing Address - Phone:323-664-4114
Mailing Address - Fax:323-664-4144
Practice Address - Street 1:1211 N VERMONT AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1748
Practice Address - Country:US
Practice Address - Phone:323-664-4114
Practice Address - Fax:323-664-4144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36895207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty