Healthcare Provider Details

I. General information

NPI: 1881616928
Provider Name (Legal Business Name): BURBANK EAST VALLEY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S BUENA VISTA ST 3RD FLOOR
BURBANK CA
91505-4569
US

IV. Provider business mailing address

PO BOX 10240
CANOGA PARK CA
91309-1240
US

V. Phone/Fax

Practice location:
  • Phone: 818-842-7145
  • Fax: 818-842-8279
Mailing address:
  • Phone: 818-704-4301
  • Fax: 818-704-9392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL MARSH
Title or Position: M.D.
Credential:
Phone: 818-842-7145