MEDICARE: SAN JUDAS MEDICAL GROUP IPA

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	302R00000X	Health Maintenance Organization

General Provider Information

NPI Number	:	1598928814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN JUDAS MEDICAL GROUP IPA

Provider Business Mailing Address
First Line	:	1075 N WESTERN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-2307
Country	:	US
Telephone Number	:	323-957-8787
Fax Number	:

Provider Business Practice Location Address
First Line	:	1075 N WESTERN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-2307
Country	:	US
Telephone Number	:	323-957-8787
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. NEJAT ROSTAMI
Credential	:	M.D.
Telephone Number	:	323-957-8787

Provider Enumeration Date	:	07/07/2008
Last Update Date	:	11/30/2009

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