Healthcare Provider Details

I. General information

NPI: 1124264635
Provider Name (Legal Business Name): AVICCENNA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2009
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 N BEDFORD DR SUITE # 312
BEVERLY HILLS CA
90210-4321
US

IV. Provider business mailing address

3392 MOTOR AVE
LOS ANGELES CA
90034-3712
US

V. Phone/Fax

Practice location:
  • Phone: 310-858-1800
  • Fax:
Mailing address:
  • Phone: 310-858-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA100198
License Number StateCA

VIII. Authorized Official

Name: DR. SEYED FARHAD N CHIMEH
Title or Position: PRESIDENT
Credential: MD
Phone: 310-858-1800