Healthcare Provider Details

I. General information

NPI: 1306320619
Provider Name (Legal Business Name): BEVERLY OB & GYN MEDICAL CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4620 BEVERLY BLVD STE 101
LOS ANGELES CA
90004-3102
US

IV. Provider business mailing address

4620 BEVERLY BLVD STE 101
LOS ANGELES CA
90004-3102
US

V. Phone/Fax

Practice location:
  • Phone: 323-462-6423
  • Fax:
Mailing address:
  • Phone: 323-462-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EDWARD S. AHN
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 323-462-6423