Provider Demographics
NPI:1841977253
Name:PRIMARY CARE SPORTS MEDICINE A MEDICAL CORPORATION
Entity type:Organization
Organization Name:PRIMARY CARE SPORTS MEDICINE A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-501-7276
Mailing Address - Street 1:18411 CLARK ST STE 302
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3541
Mailing Address - Country:US
Mailing Address - Phone:818-501-7276
Mailing Address - Fax:
Practice Address - Street 1:29229 CANWOOD ST STE 112
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-1561
Practice Address - Country:US
Practice Address - Phone:818-501-7276
Practice Address - Fax:818-501-7288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-28
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Single Specialty