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General NPI Number Information
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NPI Number | 1073987095
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Entity Type | Organization
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Legal Business Name | UNIVERSAL HEALTHCARE PROFESSIONAL MEDICAL PC
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Dates
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Enumeration Date | 11/16/2015
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Last Update Date | 09/26/2016
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Provider Practice Location Address
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Address Line | 90 N MADISON AVE
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City | PASADENA
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State | CA
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Zip | 91101-1740
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Country | US
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Telephone | 626-291-2525
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Fax | 626-898-9244
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Provider Business Mailing Address
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Address Line | 90 N MADISON AVE
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City | PASADENA
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State | CA
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Zip | 91101-1740
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Country | US
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Telephone | 626-291-2525
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Fax | 626-898-9244
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DERRICK M MYERS
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Credential | MD
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Telephone | 323-804-3031
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 545378
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License Number State | CA
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