MEDICARE: MICHAEL MERRELL VAN TIENDEREN DO

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	207LP3000X	Pediatric Anesthesiology Physician	20A19832	CA
2	207L00000X	Anesthesiology Physician	20A19832	CA

General Provider Information

NPI Number	:	1427506856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL MERRELL VAN TIENDEREN DO

Provider Business Mailing Address
First Line	:	5767 W CENTURY BLVD STE 400
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-5631
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	757 WESTWOOD PLZ STE 3325
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-2501
Country	:	US
Telephone Number	:	310-267-8678
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2016
Last Update Date	:	08/10/2023

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