MEDICARE: HOLLYWOOD INTERNAL MEDICINE 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1780449744
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLYWOOD INTERNAL MEDICINE CLINIC INC

Provider Business Mailing Address
First Line	:	5101 HOLLYWOOD BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-6105
Country	:	US
Telephone Number	:	323-426-9139
Fax Number	:	323-426-9140

Provider Business Practice Location Address
First Line	:	5101 HOLLYWOOD BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-6105
Country	:	US
Telephone Number	:	323-426-9139
Fax Number	:	323-426-9140

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	JEFFREY CRUDO
Credential	:	MD
Telephone Number	:	323-426-9139

Provider Enumeration Date	:	02/19/2024
Last Update Date	:	03/01/2024

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