Healthcare Provider Details

I. General information

NPI: 1720273683
Provider Name (Legal Business Name): HOSPITAL PEDIATRIC SPECIALISTS MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18321 CLARK ST
TARZANA CA
91356-3501
US

IV. Provider business mailing address

PO BOX 570247
TARZANA CA
91357-0247
US

V. Phone/Fax

Practice location:
  • Phone: 818-881-0800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN HALE
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 866-362-2455