=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700268372
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TARZANA SURGERY CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2015
-----------------------------------------------------
Last Update Date | 06/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18370 BURBANK BLVD #100
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-986-1070
-----------------------------------------------------
Fax | 818-986-9178
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18370 BURBANK BLVD #100
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-986-1070
-----------------------------------------------------
Fax | 818-986-9178
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | MR. MICHAEL VERMESH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 818-986-1070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------