=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356582860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC SUBSPECIALTY ASSOCIATES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2009
-----------------------------------------------------
Last Update Date | 03/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 W GLENOAKS BLVD #650
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91202-2896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-376-0228
-----------------------------------------------------
Fax | 818-788-7857
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3825 WOODCLIFF RD
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91403-5053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-376-0228
-----------------------------------------------------
Fax | 818-788-7857
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ANINDA DAS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 323-376-0228
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0208X
-----------------------------------------------------
Taxonomy Name | Pediatric Infectious Diseases Physician
-----------------------------------------------------
License Number | A55664
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------