Healthcare Provider Details

I. General information

NPI: 1114177359
Provider Name (Legal Business Name): HUSSAM Y. ANTOIN, M.D., A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S SPALDING DR STE.#301
BEVERLY HILLS CA
90212-1800
US

IV. Provider business mailing address

PO BOX 7001
TARZANA CA
91357-7001
US

V. Phone/Fax

Practice location:
  • Phone: 310-385-7755
  • Fax:
Mailing address:
  • Phone: 818-888-7815
  • Fax: 818-715-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA88484
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA88484
License Number StateCA

VIII. Authorized Official

Name: HUSSAM Y ANTOIN
Title or Position: PRESIDENT/ SOLE OWNER
Credential: M.D.
Phone: 818-888-7815