MEDICARE: ELITE MEDICAL GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center
2	207RG0300X	Geriatric Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1023996618
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	4312 WOODMAN AVE STE 300
Second Line	:
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91423-5514
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4312 WOODMAN AVE STE 300
Second Line	:
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91423-5514
Country	:	US
Telephone Number	:	818-521-1418
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	JULIE GRAND
Credential	:
Telephone Number	:	818-521-1418

Provider Enumeration Date	:	08/22/2025
Last Update Date	:	08/22/2025

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