NPIMap

Organization Active NPI

Vital Medical Group, Inc

  • Family Medicine Physician
  • Glendale, CA
National Provider Identifier
1124886437
Registry record updated Apr 22, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
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
Last updated
Apr 22, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 22, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Maxwell Jen, MDNPI 1154688810
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)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 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 IDStateProvider typePAC IDDetails
O20240515004361 CA Part B Supplier - Clinic/Group Practice 5597106930 Receives reassigned benefits from 36 practitioners
Practice locations: Glendale, CA

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 40

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 40

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.

Verify at the official NPI Registry.