Healthcare Provider Details

I. General information

NPI: 1215260377
Provider Name (Legal Business Name): BRIDGE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 05/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15720 VENTURA BLVD STE. 400
ENCINO CA
91436-2914
US

IV. Provider business mailing address

P.O. BOX 1992
SANTA MONICA CA
90406
US

V. Phone/Fax

Practice location:
  • Phone: 800-967-3309
  • Fax: 800-967-1138
Mailing address:
  • Phone: 800-967-3309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN ASHER YAKER
Title or Position: VICE PRESIDENT
Credential:
Phone: 800-967-3309