MEDICARE: SAN FERNANDO MISSION MEDICAL GRP

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	170100000X	Ph.D. Medical Genetics	A30427	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215991278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN FERNANDO MISSION MEDICAL GRP

Provider Business Mailing Address
First Line	:	8215 VAN NUYS BLVD
Second Line	:	210-204
City	:	PANORAMA CITY
State	:	CA
Zip	:	91402-4810
Country	:	US
Telephone Number	:	818-782-4325
Fax Number	:	818-782-7320

Provider Business Practice Location Address
First Line	:	8215 VAN NUYS BLVD
Second Line	:	210-204
City	:	PANORAMA CITY
State	:	CA
Zip	:	91402-4810
Country	:	US
Telephone Number	:	818-782-4325
Fax Number	:	818-782-7320

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. ERLINDA DY GREY
Credential	:	M.D.
Telephone Number	:	818-782-4325

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	10/19/2011

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Directions to “SAN FERNANDO MISSION MEDICAL GRP ” Practice Location

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