MEDICARE: SEVILLA MEDICAL GROUP 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	207R00000X	Internal Medicine Physician	A63670	CA

General Provider Information

NPI Number	:	1871757302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEVILLA MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	PO BOX 31340
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-0340
Country	:	US
Telephone Number	:	323-342-9764
Fax Number	:	323-342-9656

Provider Business Practice Location Address
First Line	:	2813 N BROADWAY
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-2611
Country	:	US
Telephone Number	:	323-342-9764
Fax Number	:	323-342-9656

Authorized Official
Title or Position	:	OWNER
Name	:	TOMAS SEVILLA
Credential	:	MD
Telephone Number	:	323-342-9764

Provider Enumeration Date	:	07/14/2008
Last Update Date	:	05/26/2010

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