Provider Demographics
NPI:1982889481
Name:MOTION PICTURE AND TELEVISION FUND MEDICAL GROUP INC
Entity Type:Organization
Organization Name:MOTION PICTURE AND TELEVISION FUND MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:SETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-876-1079
Mailing Address - Street 1:23388 MULHOLLAND DR
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-2733
Mailing Address - Country:US
Mailing Address - Phone:818-876-1636
Mailing Address - Fax:818-876-1516
Practice Address - Street 1:11550 INDIAN HILLS RD
Practice Address - Street 2:STE 200
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1200
Practice Address - Country:US
Practice Address - Phone:818-876-4770
Practice Address - Fax:818-876-4113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW12214EMedicare PIN