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General NPI Number Information
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NPI Number | 1871743856
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Entity Type | Organization
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Legal Business Name | ELDER AUDIO REHAB MEDICAL GROUP INC
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Dates
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Enumeration Date | 09/25/2008
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Last Update Date | 02/18/2011
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Provider Practice Location Address
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Address Line | 4029 E ANAHEIM ST
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City | LONG BEACH
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State | CA
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Zip | 90804-4110
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Country | US
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Telephone | 562-494-4421
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Fax | 562-494-2731
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Provider Business Mailing Address
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Address Line | 65 PINE AVE SUITE 119
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City | LONG BEACH
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State | CA
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Zip | 90802-4718
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Country | US
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Telephone | 562-760-8823
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Fax | 562-252-9505
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Authorized Official
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Title or Position | PROVIDER/COO
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Name | MR. MARSHALL EDWARD BLESOFSKY
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Credential | PA-C
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Telephone | 562-760-8823
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology 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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | FNP37597
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License Number State | CA
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