Provider Demographics
NPI:1952582249
Name:FREDRIC L EDELMAN MD A PROF CORP
Entity Type:Organization
Organization Name:FREDRIC L EDELMAN MD A PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUILERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-781-3350
Mailing Address - Street 1:16830 VENTURA BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1786
Mailing Address - Country:US
Mailing Address - Phone:818-781-3350
Mailing Address - Fax:818-781-7237
Practice Address - Street 1:16830 VENTURA BLVD STE 130
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1786
Practice Address - Country:US
Practice Address - Phone:818-781-3350
Practice Address - Fax:818-781-7237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG15613174400000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0079310Medicaid
CAGR0079310Medicaid