MEDICARE: COLUMBIA 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	208D00000X	General Practice Physician	G36895	CA
2	207Q00000X	Family Medicine Physician	G36895	CA

General Provider Information

NPI Number	:	1336365576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBIA MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	1211 N VERMONT AVE
Second Line	:	SUITE 205
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-1748
Country	:	US
Telephone Number	:	323-664-4114
Fax Number	:	323-664-4144

Provider Business Practice Location Address
First Line	:	1211 N VERMONT AVE
Second Line	:	SUITE 205
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-1748
Country	:	US
Telephone Number	:	323-664-4114
Fax Number	:	323-664-4144

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	HOVIK SIMITYAN
Credential	:
Telephone Number	:	323-664-4114

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	03/12/2008

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