Provider Demographics
NPI:1700439122
Name:CORDIAL MEDICAL GROUP
Entity type:Organization
Organization Name:CORDIAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:QUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:747-238-2544
Mailing Address - Street 1:8049 LAUREL CANYON BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605-1428
Mailing Address - Country:US
Mailing Address - Phone:747-238-2544
Mailing Address - Fax:
Practice Address - Street 1:8049 LAUREL CANYON BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-1428
Practice Address - Country:US
Practice Address - Phone:747-238-2544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty