Healthcare Provider Details

I. General information

NPI: 1417495904
Provider Name (Legal Business Name): ELECTRO DIAGNOSTIC MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5635 CAHUENGA BLVD
NORTH HOLLYWOOD CA
91601-2104
US

IV. Provider business mailing address

1407 HILLSIDE DR
GLENDALE CA
91208-2416
US

V. Phone/Fax

Practice location:
  • Phone: 818-308-7450
  • Fax:
Mailing address:
  • Phone: 818-547-9870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT12456
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberA97751
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA97751
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA97751
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License NumberA97751
License Number StateCA

VIII. Authorized Official

Name: DR. ALIASGHAR MATIN
Title or Position: PROVIDER
Credential: MD
Phone: 818-308-7450