Healthcare Provider Details

I. General information

NPI: 1689688335
Provider Name (Legal Business Name): MID-VALLEY PULMONARY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4955 VAN NUYS BLVD #502
SHERMAN OAKS CA
91403-1817
US

IV. Provider business mailing address

4955 VAN NUYS BLVD #502
SHERMAN OAKS CA
91403-1817
US

V. Phone/Fax

Practice location:
  • Phone: 818-325-0200
  • Fax: 818-325-0210
Mailing address:
  • Phone: 818-325-0200
  • Fax: 818-325-0210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number0870516
License Number StateCA

VIII. Authorized Official

Name: NECHEMIA B PELEG
Title or Position: CFO, VP
Credential: MD
Phone: 818-325-0200