Healthcare Provider Details

I. General information

NPI: 1720554041
Provider Name (Legal Business Name): MGB MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7535 LAUREL CANYON BLVD
N HOLLYWOOD CA
91605-3149
US

IV. Provider business mailing address

7535 LAUREL CANYON BLVD
N HOLLYWOOD CA
91605-3149
US

V. Phone/Fax

Practice location:
  • Phone: 818-962-5505
  • Fax:
Mailing address:
  • Phone: 818-962-5505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL REPIK
Title or Position: PRESIDENT
Credential: MD
Phone: 818-962-5505