Healthcare Provider Details

I. General information

NPI: 1104476217
Provider Name (Legal Business Name): SU SALUD MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2019
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7418 STATE ST
HUNTINGTON PARK CA
90255-5928
US

IV. Provider business mailing address

7418 STATE ST
HUNTINGTON PARK CA
90255-5928
US

V. Phone/Fax

Practice location:
  • Phone: 323-835-6298
  • Fax: 323-835-6081
Mailing address:
  • Phone: 323-835-6298
  • Fax: 323-835-6081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: ABDEL N ABDELSAYED
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 323-918-2700