Basic Information
| Provider Information | |||||||||
| NPI: | 1700117546 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANTA MONICA BAY AREA PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6029 BRISTOL PKWY | ||||||||
| Address2: | 100 | ||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902306643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104175900 | ||||||||
| FaxNumber: | 3104101001 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 SANTA MONICA BLVD | ||||||||
| Address2: | 860 | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108283209 | ||||||||
| FaxNumber: | 3108285165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2010 | ||||||||
| LastUpdateDate: | 01/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | KATZ | ||||||||
| AuthorizedOfficialFirstName: | BERNARD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-CEO | ||||||||
| AuthorizedOfficialTelephone: | 3104175900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SANTA MONICA BAY AREA PHYSICIANS | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | G44560 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | W14560 | 01 | CA | PTAN | OTHER |