Healthcare Provider Details

I. General information

NPI: 1265256176
Provider Name (Legal Business Name): SERGEY SERGEYEVICH PROGUSHEV MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2024
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18330 ROSCOE BLVD
NORTHRIDGE CA
91325-4105
US

IV. Provider business mailing address

686 MONTEREY PL
SIERRA MADRE CA
91024-2105
US

V. Phone/Fax

Practice location:
  • Phone: 747-224-4004
  • Fax:
Mailing address:
  • Phone: 912-658-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SERGEY SERGEYEVICH PROGUSHEV
Title or Position: PRESIDENT
Credential: MD
Phone: 912-658-1150