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General NPI Number Information
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NPI Number | 1508804006
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Entity Type | Organization
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Legal Business Name | IMD MEDICAL GROUP INC
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Dates
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Enumeration Date | 06/04/2006
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Last Update Date | 12/10/2015
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Provider Practice Location Address
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Address Line | 1234 N VERMONT AVE
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City | LOS ANGELES
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State | CA
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Zip | 90029-1704
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Country | US
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Telephone | 213-487-6867
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Fax | 213-487-6811
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Provider Business Mailing Address
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Address Line | 1234 N VERMONT AVE
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City | LOS ANGELES
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State | CA
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Zip | 90029-1704
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Country | US
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Telephone | 213-487-6867
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Fax | 213-487-6811
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Authorized Official
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Title or Position | PRESIDENT
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Name | IMAD EL ASMAR
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Credential | M.D.
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Telephone | 213-487-6867
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | A89382
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | A61923
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License Number State | CA
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