Provider Demographics
| NPI: | 1265530653 |
|---|---|
| Name: | CHILDREN'S HOSPITAL LOS ANGELES MEDICAL GROUP, INC. |
| Entity type: | Organization |
| Organization Name: | CHILDREN'S HOSPITAL LOS ANGELES MEDICAL GROUP, INC. |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CHIEF FINANCIAL OFFICER |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | JAMES |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | LIN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 323-361-1601 |
| Mailing Address - Street 1: | 3250 WILSHIRE BLVD STE 1101 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | LOS ANGELES |
| Mailing Address - State: | CA |
| Mailing Address - Zip Code: | 90010-1513 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 323-361-2337 |
| Mailing Address - Fax: | 323-361-8491 |
| Practice Address - Street 1: | 4650 SUNSET BLVD |
| Practice Address - Street 2: | |
| Practice Address - City: | LOS ANGELES |
| Practice Address - State: | CA |
| Practice Address - Zip Code: | 90027 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 323-361-2337 |
| Practice Address - Fax: | 323-361-8491 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-09-20 |
| Last Update Date: | 2024-07-01 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CA | GR006667A | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR0066671 | Other | MEDICAID & CALOPTIMA GROU |
| CA | GR0066678 | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR006667F | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR0066672 | Other | MEDICAID & CALOPTIMA GROU |
| CA | GR0066679 | Other | MEDICAID AND CALOPTIMA GR |
| CA | G9087701 | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR0066673 | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR006667B | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR0066674 | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR006667C | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR006667E | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR006667G | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR0066670 | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR0066675 | Medicaid | |
| CA | GR0066677 | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR0066675 | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR0066676 | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR006667D | Other | MEDICAID AND CALOPTIMA GR |
| CA | GR0066678 | Other | MEDICAID AND CALOPTIMA GR |
