Healthcare Provider Details

I. General information

NPI: 1790094639
Provider Name (Legal Business Name): RONALD A CARLISH MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2010
Last Update Date: 01/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 WILSHIRE BLVD STE 820
LOS ANGELES CA
90017-3910
US

IV. Provider business mailing address

1127 WILSHIRE BLVD STE 820
LOS ANGELES CA
90017-3910
US

V. Phone/Fax

Practice location:
  • Phone: 213-977-9421
  • Fax: 213-977-9422
Mailing address:
  • Phone: 213-977-9421
  • Fax: 213-977-9422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG15424
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License NumberA64244
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberG15424
License Number StateCA

VIII. Authorized Official

Name: DR. RONALD A CARLISH
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 213-977-9421