Provider Demographics
NPI:1427113463
Name:MID CITY ASSOCIATES MEDICAL GROUP
Entity type:Organization
Organization Name:MID CITY ASSOCIATES MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:ALMENDARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-361-4111
Mailing Address - Street 1:12610 GLENOAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-4783
Mailing Address - Country:US
Mailing Address - Phone:818-361-4111
Mailing Address - Fax:818-361-7584
Practice Address - Street 1:12610 GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-4783
Practice Address - Country:US
Practice Address - Phone:818-361-4111
Practice Address - Fax:818-361-7584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44112174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0043091Medicaid
CAGR0043091Medicaid