MEDICARE: SUPERIOR MULTI SPECIALTY 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	261QM2500X	Medical Specialty Clinic/Center	A50372	CA
2	261QE0002X	Emergency Care Clinic/Center	A50372	CA
3	261QM1300X	Multi-Specialty Clinic/Center	A50372	CA
4	261QP3300X	Pain Clinic/Center	A50372	CA
5	261QU0200X	Urgent Care Clinic/Center	A50312	CA
6	208D00000X	General Practice Physician

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	:	1770774366
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPERIOR MULTI SPECIALTY MEDICAL CLINIC INC.

Provider Business Mailing Address
First Line	:	11600 VENICE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-4014
Country	:	US
Telephone Number	:	310-390-9551
Fax Number	:	310-390-9296

Provider Business Practice Location Address
First Line	:	11600 VENICE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-4014
Country	:	US
Telephone Number	:	310-390-9551
Fax Number	:	310-390-9296

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	REZA RAY EHSAN
Credential	:	M.D.
Telephone Number	:	310-390-9551

Provider Enumeration Date	:	08/07/2007
Last Update Date	:	02/22/2010

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