Healthcare Provider Details

I. General information

NPI: 1609269885
Provider Name (Legal Business Name): A. MARSH MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S ATLANTIC BLVD
LOS ANGELES CA
90022-3211
US

IV. Provider business mailing address

615 S ATLANTIC BLVD
LOS ANGELES CA
90022-3211
US

V. Phone/Fax

Practice location:
  • Phone: 323-604-9591
  • Fax: 323-604-9594
Mailing address:
  • Phone: 323-604-9591
  • Fax: 323-604-9594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberC22547
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberC22547
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA15732
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC22547
License Number StateCA

VIII. Authorized Official

Name: MR. ALVA A MARSH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 323-604-9591