MEDICARE: SOUTH ATLANTIC 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	A41061	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710160627
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH ATLANTIC MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	5504 WHITTIER BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90022-4104
Country	:	US
Telephone Number	:	323-725-0167
Fax Number	:

Provider Business Practice Location Address
First Line	:	5504 WHITTIER BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90022-4104
Country	:	US
Telephone Number	:	323-725-0167
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	NISSAN KAHEN
Credential	:	M.D.
Telephone Number	:	323-725-0167

Provider Enumeration Date	:	12/13/2007
Last Update Date	:	07/28/2009

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