Healthcare Provider Details

I. General information

NPI: 1104127505
Provider Name (Legal Business Name): R G W MULTI SPECIALTY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 W GLENOAKS BLVD SUITE 101
GLENDALE CA
91201-1541
US

IV. Provider business mailing address

1915 W GLENOAKS BLVD SUITE 101
GLENDALE CA
91201-1541
US

V. Phone/Fax

Practice location:
  • Phone: 818-955-9902
  • Fax: 818-955-9987
Mailing address:
  • Phone: 818-955-9902
  • Fax: 818-955-9987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberA23457
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDALL G WEISSBUCH
Title or Position: OWNER
Credential: M.D.
Phone: 818-955-9902