Healthcare Provider Details

I. General information

NPI: 1134274418
Provider Name (Legal Business Name): PRIMARY CARE SPORTS MEDICINE A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18411 CLARK ST STE 302
TARZANA CA
91356-3541
US

IV. Provider business mailing address

18411 CLARK ST SUITE 302
TARZANA CA
91356-3506
US

V. Phone/Fax

Practice location:
  • Phone: 818-501-7276
  • Fax:
Mailing address:
  • Phone: 818-501-7276
  • Fax: 818-501-7288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA62510
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberA62510
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA62510
License Number StateCA

VIII. Authorized Official

Name: DR. BYRON PATTERSON
Title or Position: MEDICAL DIRECTOR
Credential: M.D
Phone: 818-501-7276