Healthcare Provider Details

I. General information

NPI: 1255534459
Provider Name (Legal Business Name): MEDICAL GROUP OF BEVERLY HILLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 N LA CIENEGA BLVD
BEVERLY HILLS CA
90211-2222
US

IV. Provider business mailing address

PO BOX 54679
LOS ANGELES CA
90054-0679
US

V. Phone/Fax

Practice location:
  • Phone: 310-967-1884
  • Fax: 310-967-1744
Mailing address:
  • Phone: 310-967-1884
  • Fax: 310-967-1744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS GORDON
Title or Position: CEO
Credential:
Phone: 310-967-1884