Healthcare Provider Details

I. General information

NPI: 1336365576
Provider Name (Legal Business Name): COLUMBIA MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 N VERMONT AVE SUITE 205
LOS ANGELES CA
90029-1748
US

IV. Provider business mailing address

1211 N VERMONT AVE SUITE 205
LOS ANGELES CA
90029-1748
US

V. Phone/Fax

Practice location:
  • Phone: 323-664-4114
  • Fax: 323-664-4144
Mailing address:
  • Phone: 323-664-4114
  • Fax: 323-664-4144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG36895
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG36895
License Number StateCA

VIII. Authorized Official

Name: HOVIK SIMITYAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 323-664-4114