MEDICARE: AMITY MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist
2	207R00000X	Internal Medicine Physician
3	207RC0200X	Critical Care Medicine (Internal Medicine) Physician
4	207RG0100X	Gastroenterology Physician
5	207RN0300X	Nephrology Physician
6	207RP1001X	Pulmonary Disease Physician
7	207W00000X	Ophthalmology Physician
8	207Y00000X	Otolaryngology Physician
9	2084P0800X	Psychiatry Physician
10	213ES0103X	Foot & Ankle Surgery Podiatrist
11	208M00000X	Hospitalist Physician	A77236	CA

General Provider Information

NPI Number	:	1164972345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMITY MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	10351 WILSHIRE BLVD
Second Line	:	202
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-4736
Country	:	US
Telephone Number	:	310-801-8333
Fax Number	:	877-563-0602

Provider Business Practice Location Address
First Line	:	2080 CENTURY PARK E STE 608
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90067-2009
Country	:	US
Telephone Number	:	310-801-8333
Fax Number	:	877-563-0602

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MICHAEL WATSON
Credential	:
Telephone Number	:	562-305-9238

Provider Enumeration Date	:	10/11/2016
Last Update Date	:	03/17/2018

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