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General NPI Number Information
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NPI Number | 1942334958
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Entity Type | Organization
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Legal Business Name | ST. MICHAEL'S NEUROLOGY MEDICAL CORP
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Dates
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Enumeration Date | 03/15/2007
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Last Update Date | 03/10/2009
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Provider Practice Location Address
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Address Line | 1141 W REDONDO BEACH BLVD SUITE 207
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City | GARDENA
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State | CA
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Zip | 90247-3586
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Country | US
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Telephone | 310-225-5599
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Fax | 310-225-5660
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Provider Business Mailing Address
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Address Line | 1141 W REDONDO BEACH BLVD SUITE 207
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City | GARDENA
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State | CA
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Zip | 90247-3586
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Country | US
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Telephone | 310-225-5599
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Fax | 310-225-5660
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SHERIF A DIMYAN
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Credential | D.O.
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Telephone | 310-225-5599
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204D00000X
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Taxonomy Name | Neuromusculoskeletal Medicine & OMM Physician
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License Number | 20A6410
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2084N0600X
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Taxonomy Name | Clinical Neurophysiology Physician
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License Number | 20A6410
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 2084P2900X
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Taxonomy Name | Pain Medicine (Psychiatry & Neurology) Physician
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License Number | 20A6410
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 2084S0012X
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Taxonomy Name | Sleep Medicine (Psychiatry & Neurology) Physician
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License Number | 20A6410
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License Number State | CA
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Taxonomy #5
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Taxonomy Code | 2084V0102X
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Taxonomy Name | Vascular Neurology Physician
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License Number | 20A6410
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License Number State | CA
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Taxonomy #6
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 20A6140
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License Number State | CA
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