Healthcare Provider Details

I. General information

NPI: 1952014698
Provider Name (Legal Business Name): CRESCENT PHYSICIAN GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2022
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2784 CASIANO RD
LOS ANGELES CA
90077-1524
US

IV. Provider business mailing address

601 N CRESCENT DR
BEVERLY HILLS CA
90210-3329
US

V. Phone/Fax

Practice location:
  • Phone: 310-409-6559
  • Fax: 213-745-0152
Mailing address:
  • Phone: 310-409-6559
  • Fax: 213-745-0152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL YADEGARI
Title or Position: CEO
Credential: MD
Phone: 310-409-6559