Provider Demographics
NPI:1427109388
Name:MAGED S MIKHAIL A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MAGED S MIKHAIL A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAGED
Authorized Official - Middle Name:S
Authorized Official - Last Name:MIKHAIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-654-0520
Mailing Address - Street 1:18425 BURBANK BLVD
Mailing Address - Street 2:SUITE #102
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2806
Mailing Address - Country:US
Mailing Address - Phone:818-654-0520
Mailing Address - Fax:818-654-0596
Practice Address - Street 1:18425 BURBANK BLVD.
Practice Address - Street 2:SUITE #102
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2806
Practice Address - Country:US
Practice Address - Phone:818-654-0520
Practice Address - Fax:818-654-0596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45367174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G453670Medicaid
CAG45367AMedicare PIN
CAW20940Medicare PIN