Healthcare Provider Details

I. General information

NPI: 1073574000
Provider Name (Legal Business Name): PHILLIP JORGE MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3828 DELMAS TER
CULVER CITY CA
90232-2713
US

IV. Provider business mailing address

PO BOX 7001
TARZANA CA
91357-7001
US

V. Phone/Fax

Practice location:
  • Phone: 310-836-7000
  • Fax: 818-715-1722
Mailing address:
  • Phone: 818-888-7815
  • Fax: 818-715-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG78921
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG78921
License Number StateCA

VIII. Authorized Official

Name: PHILLIP JORGE
Title or Position: DIRECT OWNER
Credential: M.D.
Phone: 818-888-7815