Healthcare Provider Details

I. General information

NPI: 1801079728
Provider Name (Legal Business Name): SOUTH ATLANTIC MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 12/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11518 GARVEY AVE
EL MONTE CA
91732-3306
US

IV. Provider business mailing address

5504 WHITTIER BLVD
LOS ANGELES CA
90022-4104
US

V. Phone/Fax

Practice location:
  • Phone: 626-575-4584
  • Fax:
Mailing address:
  • Phone: 323-725-0167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA41061
License Number StateCA

VIII. Authorized Official

Name: NISSAN KAHEN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 323-725-0167