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General NPI Number Information
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NPI Number | 1215037049
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Entity Type | Organization
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Legal Business Name | PACIFIC PALISADES MEDICAL GROUP INC.
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Dates
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Enumeration Date | 09/22/2006
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Last Update Date | 05/14/2021
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Provider Practice Location Address
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Address Line | 15200 W SUNSET BLVD SUITE 107
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City | PACIFIC PALISADES
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State | CA
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Zip | 90272-3619
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Country | US
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Telephone | 310-459-7736
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Fax | 310-230-0284
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Provider Business Mailing Address
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Address Line | 15200 W SUNSET BLVD SUITE 107
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City | PACIFIC PALISADES
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State | CA
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Zip | 90272-3619
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Country | US
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Telephone | 310-459-7736
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Fax | 310-230-0284
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Authorized Official
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Title or Position | PRESIDENT
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Name | RICHARD JOHNSON
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Credential | M.D.
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Telephone | 310-459-7736
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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 |
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License Number State |
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