MEDICARE: BEVERLY OB & GYN MEDICAL CENTER 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	261QP2300X	Primary Care Clinic/Center
2	207VG0400X	Gynecology Physician

General Provider Information

NPI Number	:	1306320619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEVERLY OB & GYN MEDICAL CENTER INC.

Provider Business Mailing Address
First Line	:	4620 BEVERLY BLVD STE 101
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-3102
Country	:	US
Telephone Number	:	323-462-6423
Fax Number	:

Provider Business Practice Location Address
First Line	:	4620 BEVERLY BLVD STE 101
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-3102
Country	:	US
Telephone Number	:	323-462-6423
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	EDWARD S. AHN
Credential	:	M.D.
Telephone Number	:	323-462-6423

Provider Enumeration Date	:	09/21/2018
Last Update Date	:	09/27/2018

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