Healthcare Provider Details

I. General information

NPI: 1013255280
Provider Name (Legal Business Name): FACEY MEDICAL GROUP A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15451 SAN FERNANDO MISSION BLVD SUITE 200
MISSION HILLS CA
91345-1368
US

IV. Provider business mailing address

15451 SAN FERNANDO MISSION BLVD SUITE 200
MISSION HILLS CA
91345-1368
US

V. Phone/Fax

Practice location:
  • Phone: 818-837-5785
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: FREDRICK RUSSO
Title or Position: PRESIDENT
Credential: MD
Phone: 818-837-5785