Provider Demographics
NPI:1700898269
Name:MERCY MEDICAL GROUP OF SPECIALISTS
Entity Type:Organization
Organization Name:MERCY MEDICAL GROUP OF SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FAKHRIRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GHAHARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-845-6800
Mailing Address - Street 1:421 E ANGELENO AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-2286
Mailing Address - Country:US
Mailing Address - Phone:818-845-6800
Mailing Address - Fax:818-843-7871
Practice Address - Street 1:421 E ANGELENO AVE STE 102
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91501-2286
Practice Address - Country:US
Practice Address - Phone:818-845-6800
Practice Address - Fax:818-843-7871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1700898269OtherNPI