Healthcare Provider Details

I. General information

NPI: 1174252951
Provider Name (Legal Business Name): MQM MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12826 VICTORY BLVD STE E
N HOLLYWOOD CA
91606-3065
US

IV. Provider business mailing address

5682 DAWN FALLS ST
LAS VEGAS NV
89148-7650
US

V. Phone/Fax

Practice location:
  • Phone: 818-583-0055
  • Fax: 818-583-0054
Mailing address:
  • Phone: 858-997-9105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK BERNARDI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 858-997-9105