Provider Demographics
NPI:1104476217
Name:SU SALUD MEDICAL GROUP INC
Entity type:Organization
Organization Name:SU SALUD MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ABDEL
Authorized Official - Middle Name:N
Authorized Official - Last Name:ABDELSAYED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-918-2700
Mailing Address - Street 1:7418 STATE ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5928
Mailing Address - Country:US
Mailing Address - Phone:323-835-6298
Mailing Address - Fax:323-835-6081
Practice Address - Street 1:7418 STATE ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5928
Practice Address - Country:US
Practice Address - Phone:323-835-6298
Practice Address - Fax:323-835-6081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-19
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1922164961Medicaid