Provider Demographics
NPI:1811440035
Name:AMWELL MEDICAL GROUP INC
Entity type:Organization
Organization Name:AMWELL MEDICAL GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PETROS
Authorized Official - Middle Name:
Authorized Official - Last Name:HAJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-855-9406
Mailing Address - Street 1:13094 BORDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-4211
Mailing Address - Country:US
Mailing Address - Phone:818-855-9406
Mailing Address - Fax:818-475-1732
Practice Address - Street 1:13094 BORDEN AVE
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-4211
Practice Address - Country:US
Practice Address - Phone:818-855-9406
Practice Address - Fax:818-475-1732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty