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General NPI Number Information
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NPI Number | 1790705267
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Entity Type | Organization
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Legal Business Name | SOUTH ATLANTIC MEDICAL GROUP
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Dates
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Enumeration Date | 07/20/2006
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Last Update Date | 07/16/2008
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Provider Practice Location Address
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Address Line | 5504 WHITTIER BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90022-4104
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Country | US
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Telephone | 323-725-0167
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Fax | 323-725-6933
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Provider Business Mailing Address
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Address Line | 5504 WHITTIER BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90022-4104
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Country | US
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Telephone | 323-725-0167
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Fax | 323-725-6933
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | NISSAN KAHEN
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Credential | M.D.,
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Telephone | 323-725-0167
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A41061
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License Number State | CA
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