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General NPI Number Information
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NPI Number | 1760525752
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Entity Type | Organization
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Legal Business Name | FOOTHILL SURGICAL SPECIALISTS MEDICAL GROUP
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Dates
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Enumeration Date | 02/15/2007
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Last Update Date | 01/08/2014
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Provider Practice Location Address
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Address Line | 1560 E. CHEVY CHASE DR. SUITE 430
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City | GLENDALE
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State | CA
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Zip | 91206-4197
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Country | US
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Telephone | 818-243-1135
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Fax | 818-243-9332
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Provider Business Mailing Address
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Address Line | 1560 E. CHEVY CHASE DR. SUITE 430
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City | GLENDALE
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State | CA
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Zip | 91206-4197
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Country | US
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Telephone | 818-243-1135
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Fax | 818-243-9332
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Authorized Official
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Title or Position | PRESIDENT/MD
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Name | SAMUEL H. CARVAJAL JR.
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Credential | MD
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Telephone | 818-243-1135
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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