1609989425 NPI number — GLENDALE RETINA ASSOCIATES MEDICAL GROUP INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609989425 NPI number — GLENDALE RETINA ASSOCIATES MEDICAL GROUP INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLENDALE RETINA ASSOCIATES MEDICAL GROUP INC.
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:
Provider Other Organization Name Type Code:
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:
1609989425
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1025 N BRAND BLVD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91202-2950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-230-2140
Provider Business Mailing Address Fax Number:
818-230-2148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1025 N BRAND BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91202-2950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-230-2140
Provider Business Practice Location Address Fax Number:
818-230-2148
Provider Enumeration Date:
08/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOGANI
Authorized Official First Name:
SANJAY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-886-6700

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0104990 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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