Healthcare Provider Details

I. General information

NPI: 1780707737
Provider Name (Legal Business Name): UTI-EHRLICH MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 UCLA MEDICAL PLZ SUITE 690
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

100 UCLA MEDICAL PLZ SUITE 690
LOS ANGELES CA
90095-0001
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-6865
  • Fax: 310-206-6600
Mailing address:
  • Phone: 310-825-6865
  • Fax: 310-206-6600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberG14024
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberG14024
License Number StateCA

VIII. Authorized Official

Name: JUDIE GARNETT
Title or Position: MANAGER
Credential:
Phone: 310-825-6865