MEDICARE: SERGEY LYASS, A PROFESSIONAL CORPORATION

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	208600000X	Surgery Physician	A80181	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	:	1780760231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERGEY LYASS, A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	4301 GRIMES PL
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91316-4361
Country	:	US
Telephone Number	:	310-623-1786
Fax Number	:	310-693-5334

Provider Business Practice Location Address
First Line	:	6404 WILSHIRE BLVD STE 701
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5509
Country	:	US
Telephone Number	:	310-623-1786
Fax Number	:	310-623-1922

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SERGEY LYASS
Credential	:
Telephone Number	:	310-623-1786

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	01/13/2026

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