Provider Demographics
NPI:1215991278
Name:SAN FERNANDO MISSION MEDICAL GRP
Entity type:Organization
Organization Name:SAN FERNANDO MISSION MEDICAL GRP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERLINDA
Authorized Official - Middle Name:DY
Authorized Official - Last Name:GREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-782-4325
Mailing Address - Street 1:8215 VAN NUYS BLVD
Mailing Address - Street 2:210-204
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-4810
Mailing Address - Country:US
Mailing Address - Phone:818-782-4325
Mailing Address - Fax:818-782-7320
Practice Address - Street 1:8215 VAN NUYS BLVD
Practice Address - Street 2:210-204
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-4810
Practice Address - Country:US
Practice Address - Phone:818-782-4325
Practice Address - Fax:818-782-7320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30427170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0059210Medicaid
CAGR0059210Medicaid
W13008Medicare PIN