Provider Demographics
NPI:1962507103
Name:OTOSURGICAL GROUP MEDICAL CLINIC, INC
Entity type:Organization
Organization Name:OTOSURGICAL GROUP MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALMA
Authorized Official - Middle Name:R
Authorized Official - Last Name:ORDAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-201-0728
Mailing Address - Street 1:2080 CENTURY PARK E
Mailing Address - Street 2:SUITE 1700
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2001
Mailing Address - Country:US
Mailing Address - Phone:310-201-0728
Mailing Address - Fax:310-201-9665
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:SUITE 1700
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-201-0728
Practice Address - Fax:310-201-9665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW036Medicare ID - Type UnspecifiedMEDICARE NUMBER