=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770686347
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOCAL PSYCHIATRIC MEDICAL GROUP, A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2006
-----------------------------------------------------
Last Update Date | 06/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3250 WILSHIRE BLVD SUITE 930
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-1438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-739-0019
-----------------------------------------------------
Fax | 213-739-0091
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3250 WILSHIRE BLVD SUITE 930
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-1438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-739-0019
-----------------------------------------------------
Fax | 213-739-0091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | STUART L ZUBRICK
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 213-739-0019
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------