Healthcare Provider Details

I. General information

NPI: 1396720371
Provider Name (Legal Business Name): PACIFIC PEDIATRIC CARDIOLOGY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 BELLEFONTAINE ST STE 405
PASADENA CA
91105-3132
US

IV. Provider business mailing address

50 BELLEFONTAINE ST STE 405
PASADENA CA
91105-3132
US

V. Phone/Fax

Practice location:
  • Phone: 626-796-9259
  • Fax: 626-449-8560
Mailing address:
  • Phone: 626-796-9259
  • Fax: 626-449-8560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: LENNIS BURKE
Title or Position: PRESIDENT
Credential: MD
Phone: 626-796-9259