Provider Demographics
NPI:1215079751
Name:RALPH POTKIN MD A MEDICAL CORP
Entity type:Organization
Organization Name:RALPH POTKIN MD A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:T
Authorized Official - Last Name:POTKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-551-1178
Mailing Address - Street 1:1125 S BEVERLY DR
Mailing Address - Street 2:SUITE 406
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1148
Mailing Address - Country:US
Mailing Address - Phone:310-551-1178
Mailing Address - Fax:310-551-2047
Practice Address - Street 1:1125 S BEVERLY DR
Practice Address - Street 2:SUITE 406
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1148
Practice Address - Country:US
Practice Address - Phone:310-551-1178
Practice Address - Fax:310-551-2047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0069770Medicaid
CAGR0069770Medicaid