Healthcare Provider Details

I. General information

NPI: 1588098842
Provider Name (Legal Business Name): EAST WEST BARUCH MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2013
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4811 E FLORENCE AVE
BELL CA
90201
US

IV. Provider business mailing address

2661 E FLORENCE AVE SUITE B
HUNTINGTON PARK CA
90255
US

V. Phone/Fax

Practice location:
  • Phone: 213-472-6651
  • Fax:
Mailing address:
  • Phone: 213-472-6651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ADEL BOUTROS
Title or Position: PRESIDENT
Credential: MD
Phone: 323-370-7430