=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508139957
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLDEN STATE BONE AND JOINT CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2012
-----------------------------------------------------
Last Update Date | 05/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9033 WILSHIRE BLVD SUITE 403
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90210-1847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-858-3800
-----------------------------------------------------
Fax | 888-589-6241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9033 WILSHIRE BLVD SUITE 403
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90210-1847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-858-3800
-----------------------------------------------------
Fax | 888-589-6241
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MATTHEW J. ENNA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 310-858-3880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0106X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Hand Surgery Physician
-----------------------------------------------------
License Number | A100628
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | A100628
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | A100628
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------