Active NPI
Vital Medical Group, Inc
- Family Medicine Physician
- Glendale, CA
National Provider Identifier
1124886437
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- Legal business name
- VITAL MEDICAL GROUP, INC
- Practice address
- 1314 W Glenoaks Blvd Ste 205
Glendale, CA 91201-4890 - Phone
- (818) 396-5158
- Fax
- (818) 396-5073
- NPI assigned
- Mar 11, 2024
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Mr. Maxwell Jen, MD
- Title
- Medical Director
- Phone
- (818) 396-5158
Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | Primary |
Addresses
Primary practice location
1314 W Glenoaks Blvd Ste 205
Glendale, CA 91201-4890
Mailing address
1314 W Glenoaks Blvd Ste 205
Glendale, CA 91201-4890
Phone (818) 396-5158
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20240515004361 | CA | Part B Supplier - Clinic/Group Practice | 5597106930 |
Receives reassigned benefits from 36 practitioners Practice locations: Glendale, CA |
National Provider Directory
National Provider DirectoryLocations
1314 W Glenoaks Blvd
Ste 205
Glendale, CA 91201
Phone (818) 396-5158
Practitioners & affiliated clinicians
Practitioners 40
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1710115200000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1713744000000",
"number": "1124886437",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1314 W GLENOAKS BLVD STE 205",
"city": "GLENDALE",
"state": "CA",
"postal_code": "912014890",
"telephone_number": "818-396-5158",
"fax_number": "818-396-5073"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1314 W GLENOAKS BLVD STE 205",
"city": "GLENDALE",
"state": "CA",
"postal_code": "912014890",
"telephone_number": "818-396-5158",
"fax_number": "818-396-5073"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "VITAL MEDICAL GROUP, INC",
"organizational_subpart": "NO",
"enumeration_date": "2024-03-11",
"last_updated": "2024-04-22",
"certification_date": "2024-04-22",
"status": "A",
"authorized_official_last_name": "JEN",
"authorized_official_first_name": "MAXWELL",
"authorized_official_title_or_position": "MEDICAL DIRECTOR",
"authorized_official_telephone_number": "818-396-5158",
"authorized_official_name_prefix": "Mr.",
"authorized_official_credential": "MD"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Family Medicine",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Glendale, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 22, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.