Healthcare Provider Details

I. General information

NPI: 1093023780
Provider Name (Legal Business Name): HUNTINGTON TRAUMA SURGERY MED GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 S FAIR OAKS AVE SUITE 101
PASADENA CA
91105-2622
US

IV. Provider business mailing address

PO BOX 80248
SAN MARINO CA
91118-8248
US

V. Phone/Fax

Practice location:
  • Phone: 626-449-4859
  • Fax: 626-403-0311
Mailing address:
  • Phone: 626-768-4415
  • Fax: 626-768-4421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA75419
License Number StateCA

VIII. Authorized Official

Name: AMAL K OBAID
Title or Position: PRESIDENT
Credential: MD
Phone: 626-683-3030