Provider Demographics
| NPI: | 1114947058 |
|---|---|
| Name: | CHOICE PROVIDERS MEDICAL GROUP INC |
| Entity type: | Organization |
| Organization Name: | CHOICE PROVIDERS MEDICAL GROUP INC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | SECRETARY |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | HANY |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | MALEK |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | DC |
| Authorized Official - Phone: | 818-705-7200 |
| Mailing Address - Street 1: | 17750 SHERMAN WAY |
| Mailing Address - Street 2: | STE 101 |
| Mailing Address - City: | RESEDA |
| Mailing Address - State: | CA |
| Mailing Address - Zip Code: | 91335-3380 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 818-705-7200 |
| Mailing Address - Fax: | 818-343-0805 |
| Practice Address - Street 1: | 17750 SHERMAN WAY |
| Practice Address - Street 2: | STE 101 |
| Practice Address - City: | RESEDA |
| Practice Address - State: | CA |
| Practice Address - Zip Code: | 91335-3380 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 818-705-7200 |
| Practice Address - Fax: | 818-343-0805 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-07-21 |
| Last Update Date: | 2008-05-29 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| CA | A44927 | 207R00000X |
| CA | C30241 | 207X00000X |
| CA | C31379 | 207X00000X |
| CA | A25062 | 208000000X |
| CA | A54207 | 208000000X |
| CA | G78404 | 208VP0000X |
| CA | PA13428 | 363A00000X |
| CA | DC21916 | 111N00000X |
| CA | DC28504 | 111N00000X |
| CA | DC20140 | 111N00000X |
| CA | DC20098 | 111N00000X |
| CA | 173F00000X | 173F00000X |
| CA | A35585 | 207Q00000X |
| CA | A64420 | 207R00000X |
| CA | A36588 | 207Q00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 208VP0000X | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | Group - Multi-Specialty |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 111N00000X | Chiropractic Providers | Chiropractor | Group - Multi-Specialty | |
| No | 173F00000X | Other Service Providers | Sleep Specialist, PhD | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CA | ZZZ50145Z | Other | BLUE SHEILD (RESEDA) |
| CA | ZZZ50147Z | Other | BLUE SHEILD (INGLEWOOD) |
| CA | ZZZ50174Z | Other | BLUE SHEILD (S.B.) |
| CA | ZZZ50176Z | Other | BLUE SHEILD (C.P) |
| CA | ZZZ501722Z | Other | BLUE SHEILD (G.H.) |
| CA | ZZZ50172Z | Other | BLUE SHEILD (EL MONTE) |
| CA | ZZZ50173Z | Other | BLUE SHEILD (PASADENA) |
| CA | GR0102431 | Medicaid | |
| CA | GR0102433 | Medicaid | |
| CA | ZZZ50146Z | Other | BLUE SHEILD (L.A.) |
| CA | GR0102434 | Medicaid | |
| CA | ZZZ501752 | Other | BLUE SHEILD |
| CA | GR0102430 | Medicaid | |
| CA | GR0102432 | Medicaid | |
| CA | GR0102430 | Medicaid |
