Healthcare Provider Details

I. General information

NPI: 1528345915
Provider Name (Legal Business Name): BALDWIN PARK MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14362 EAST RAMONA BLVD.
BALDWIN PARK CA
91706
US

IV. Provider business mailing address

14362 RAMONA BLVD
BALDWIN PARK CA
91706-3241
US

V. Phone/Fax

Practice location:
  • Phone: 626-337-0676
  • Fax: 626-813-4342
Mailing address:
  • Phone: 626-337-0676
  • Fax: 626-813-4342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A7473
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA20545
License Number StateCA

VIII. Authorized Official

Name: SHERRY ROSTAMI
Title or Position: ADMINISTRATOR
Credential:
Phone: 626-337-0676