1730124462 NPI number — SANTA MONICA BAY AREA PHYSICIANS

Table of content: (NPI 1730124462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730124462 NPI number — SANTA MONICA BAY AREA PHYSICIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANTA MONICA BAY AREA PHYSICIANS
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:
PLAZA MARINA WALK0IN URGENT CARE
Provider Other Organization Name Type Code:
3
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:
1730124462
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6029 BRISTOL PKWY
Provider Second Line Business Mailing Address:
100
Provider Business Mailing Address City Name:
CULVER CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90230-6643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-417-5901
Provider Business Mailing Address Fax Number:
310-410-1001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4560 ADMIRALTY WAY
Provider Second Line Business Practice Location Address:
100
Provider Business Practice Location Address City Name:
MARINA DEL REY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90292-5423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-827-3700
Provider Business Practice Location Address Fax Number:
310-578-5379
Provider Enumeration Date:
06/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KATZ
Authorized Official First Name:
BERNARD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
310-417-5900

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: W14560F . This is a "MEDICARE LOCATION PTAN NUMBER" identifier . This identifiers is of the category "OTHER".




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