Healthcare Provider Details

I. General information

NPI: 1760525752
Provider Name (Legal Business Name): FOOTHILL SURGICAL SPECIALISTS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 E. CHEVY CHASE DR. SUITE 430
GLENDALE CA
91206-4197
US

IV. Provider business mailing address

1560 E. CHEVY CHASE DR. SUITE 430
GLENDALE CA
91206-4197
US

V. Phone/Fax

Practice location:
  • Phone: 818-243-1135
  • Fax: 818-243-9332
Mailing address:
  • Phone: 818-243-1135
  • Fax: 818-243-9332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL H. CARVAJAL JR.
Title or Position: PRESIDENT/MD
Credential: MD
Phone: 818-243-1135