Provider Demographics
NPI:1881616928
Name:BURBANK EAST VALLEY MEDICAL GROUP
Entity type:Organization
Organization Name:BURBANK EAST VALLEY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-842-7145
Mailing Address - Street 1:PO BOX 10240
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91309-1240
Mailing Address - Country:US
Mailing Address - Phone:818-704-4301
Mailing Address - Fax:818-704-9392
Practice Address - Street 1:201 S BUENA VISTA ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4569
Practice Address - Country:US
Practice Address - Phone:818-842-7145
Practice Address - Fax:818-842-8279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16461Medicare ID - Type Unspecified