Provider Demographics
NPI:1871757302
Name:SEVILLA MEDICAL GROUP INC
Entity type:Organization
Organization Name:SEVILLA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SEVILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-342-9764
Mailing Address - Street 1:PO BOX 31340
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0340
Mailing Address - Country:US
Mailing Address - Phone:323-342-9764
Mailing Address - Fax:323-342-9656
Practice Address - Street 1:2813 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-2611
Practice Address - Country:US
Practice Address - Phone:323-342-9764
Practice Address - Fax:323-342-9656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-14
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63670207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty