=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528340437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMETI-BIRDJANDI MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2011
-----------------------------------------------------
Last Update Date | 02/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6719 ALVARADO RD SUITE 100
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92120-5270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-495-0971
-----------------------------------------------------
Fax | 858-495-0991
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 34120
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89533-4120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-747-5050
-----------------------------------------------------
Fax | 877-747-5005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MAHNAZ SAMETI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 858-495-0971
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | C54511
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | A89932
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------