MEDICARE: SERPAH MEDICAL PC

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	207RI0001X	Clinical & Laboratory Immunology (Internal Medicine) Physician
2	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1619445640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERPAH MEDICAL PC

Provider Business Mailing Address
First Line	:	2080 CENTURY PARK E STE 710
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90067-2010
Country	:	US
Telephone Number	:	424-274-3211
Fax Number	:

Provider Business Practice Location Address
First Line	:	2080 CENTURY PARK E STE 710
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90067-2010
Country	:	US
Telephone Number	:	424-274-3211
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KEVIN MATTHEW NELSON
Credential	:
Telephone Number	:	310-883-8920

Provider Enumeration Date	:	11/07/2018
Last Update Date	:	11/07/2018

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