Provider Demographics
NPI:1154378362
Name:BROTMAN MEDICAL ANESTHESIA GROUP
Entity type:Organization
Organization Name:BROTMAN MEDICAL ANESTHESIA GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-888-7815
Mailing Address - Street 1:PO BOX 7001
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-7001
Mailing Address - Country:US
Mailing Address - Phone:818-888-7815
Mailing Address - Fax:818-715-1722
Practice Address - Street 1:20750 VENTURA BLVD
Practice Address - Street 2:STE. #210
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2338
Practice Address - Country:US
Practice Address - Phone:818-888-7815
Practice Address - Fax:818-715-1722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69217207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0103820OtherEDS MEDICAL
CAW20213Medicare PIN