Healthcare Provider Details

I. General information

NPI: 1396762100
Provider Name (Legal Business Name): MOTION PICTURE AND TELEVISION FUND MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 02/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 W RIVERSIDE DR
BURBANK CA
91505-4044
US

IV. Provider business mailing address

23388 MULHOLLAND DR MAILSTOP 62
WOODLAND HILLS CA
91364-2733
US

V. Phone/Fax

Practice location:
  • Phone: 818-556-2700
  • Fax:
Mailing address:
  • Phone: 818-876-1636
  • Fax: 818-876-1516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. SETH ELLIS
Title or Position: VP CHIEF OPERATING OFFICER
Credential:
Phone: 818-876-1079