MEDICARE: LANKERSHIM MEDICAL CLINIC 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	208000000X	Pediatrics Physician	A043704	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	:	1528226073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LANKERSHIM MEDICAL CLINIC INC

Provider Business Mailing Address
First Line	:	6056 LANKERSHIM BLVD
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91606-4806
Country	:	US
Telephone Number	:	818-761-2300
Fax Number	:	818-761-5066

Provider Business Practice Location Address
First Line	:	6056 LANKERSHIM BLVD
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91606-4806
Country	:	US
Telephone Number	:	818-761-2300
Fax Number	:	818-761-5066

Authorized Official
Title or Position	:	PROPIETOR
Name	:	BEHROUZ BROOMAND
Credential	:	M.D
Telephone Number	:	818-761-2300

Provider Enumeration Date	:	05/30/2008
Last Update Date	:	05/30/2008

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