Provider Demographics
NPI:1871743856
Name:ELDER AUDIO REHAB MEDICAL GROUP INC
Entity type:Organization
Organization Name:ELDER AUDIO REHAB MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BLESOFSKY
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:562-760-8823
Mailing Address - Street 1:65 PINE AVE
Mailing Address - Street 2:SUITE 119
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4718
Mailing Address - Country:US
Mailing Address - Phone:562-760-8823
Mailing Address - Fax:562-252-9505
Practice Address - Street 1:4029 E ANAHEIM ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-4110
Practice Address - Country:US
Practice Address - Phone:562-494-4421
Practice Address - Fax:562-494-2731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-25
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Y00000X
CAFNP37597363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABT389BMedicare PIN
CABT389AMedicare PIN