Basic Information
| Provider Information | |||||||||
| NPI: | 1609890169 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANTA MONICA BAY AREA PHYSICIANS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SANTA MONICA BAY AREA PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6029 BRISTOL PKWY | ||||||||
| Address2: | 100 | ||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902306643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104175901 | ||||||||
| FaxNumber: | 3104101001 | ||||||||
| Practice Location | |||||||||
| Address1: | 804 7TH ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904031408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103955588 | ||||||||
| FaxNumber: | 3103956313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 05/29/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KATZ | ||||||||
| AuthorizedOfficialFirstName: | BERNARD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3104175900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SANTA MONICA BAY AREA PHYSICIANS | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | W14560 | 01 | CA | MEDICARE LOCATION PTAN | OTHER |