Provider Demographics
NPI:1912963364
Name:GLENDALE INTERNAL MEDICINE AND CARDIOLOGY MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:GLENDALE INTERNAL MEDICINE AND CARDIOLOGY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:SADRZADEH
Authorized Official - Last Name:RAFIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-242-4191
Mailing Address - Street 1:500 N CENTRAL AVE STE 800
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-3345
Mailing Address - Country:US
Mailing Address - Phone:818-242-4191
Mailing Address - Fax:818-242-4811
Practice Address - Street 1:500 N CENTRAL AVE STE 800
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-3345
Practice Address - Country:US
Practice Address - Phone:818-242-4191
Practice Address - Fax:818-242-4811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ77955ZMedicaid
CAZZZ77955ZMedicaid