=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801199864
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONTERREY PARK MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2010
-----------------------------------------------------
Last Update Date | 12/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 941 S ATLANTIC BLVD SUITE 101
-----------------------------------------------------
City | MONTEREY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91754-4722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-458-8401
-----------------------------------------------------
Fax | 626-458-5606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 629 W VERMONT AVE APT 14B
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-367-9631
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RHEUMATOLOGIST/MD
-----------------------------------------------------
Name | DR. RAMACHANDRAN SRINIVASAN
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 626-458-8401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA20958
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA20958
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------