Healthcare Provider Details

I. General information

NPI: 1700898269
Provider Name (Legal Business Name): MERCY MEDICAL GROUP OF SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 E ANGELENO AVE STE 102
BURBANK CA
91501-2286
US

IV. Provider business mailing address

421 E ANGELENO AVE STE 102
BURBANK CA
91501-2286
US

V. Phone/Fax

Practice location:
  • Phone: 818-845-6800
  • Fax: 818-843-7871
Mailing address:
  • Phone: 818-845-6800
  • Fax: 818-843-7871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: FAKHRIRAN GHAHARI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 818-845-6800