=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326459256
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGED BASILIOS, MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2014
-----------------------------------------------------
Last Update Date | 05/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4505 E SLAUSON AVE SUITE E
-----------------------------------------------------
City | MAYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90270-4955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-771-0080
-----------------------------------------------------
Fax | 323-771-0090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4505 E SLAUSON AVE SUITE E
-----------------------------------------------------
City | MAYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90270-4955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-771-0080
-----------------------------------------------------
Fax | 323-771-0090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MAGED BASILIOS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 323-771-0080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | A061990
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------