MEDICARE: MARY KASEM MD

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	A72302	CA

General Provider Information

NPI Number	:	1982639993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KASEM MD

Provider Business Mailing Address
First Line	:	840 TOWNE CENTER DR
Second Line	:
City	:	POMONA
State	:	CA
Zip	:	91767-5900
Country	:	US
Telephone Number	:	909-398-1500
Fax Number	:	909-398-1488

Provider Business Practice Location Address
First Line	:	430 W BASELINE RD
Second Line	:
City	:	CLAREMONT
State	:	CA
Zip	:	91711-1607
Country	:	US
Telephone Number	:	909-621-3916
Fax Number	:	909-625-0903

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	09/12/2018

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