1538247424 NPI number — ELLSWORTH GRANT, M.D., MEDICAL CORP

Table of content: (NPI 1538247424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538247424 NPI number — ELLSWORTH GRANT, M.D., MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELLSWORTH GRANT, M.D., MEDICAL CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ELLSWORTH R. GRANT, M.D.
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538247424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1245 WILSHIRE BLVD
Provider Second Line Business Mailing Address:
SUITE 801
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90017-4810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-481-3948
Provider Business Mailing Address Fax Number:
213-481-1697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1245 WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
SUITE 801
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90017-4810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-481-3948
Provider Business Practice Location Address Fax Number:
213-481-1697
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VENTURA
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
213-481-3948

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  G073084 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G730842 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G073084 . This is a "CALIFORNIA STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G730841 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: AY691 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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