Provider Demographics
NPI:1366195265
Name:KWB MEDICAL GROUP, INC
Entity type:Organization
Organization Name:KWB MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-858-0211
Mailing Address - Street 1:7537 LAUREL CANYON BLVD UNIT A
Mailing Address - Street 2:
Mailing Address - City:N HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605-3149
Mailing Address - Country:US
Mailing Address - Phone:818-858-0211
Mailing Address - Fax:
Practice Address - Street 1:7537 LAUREL CANYON BLVD UNIT A
Practice Address - Street 2:
Practice Address - City:N HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-3149
Practice Address - Country:US
Practice Address - Phone:818-858-0211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC53406OtherMEDICAL LICENSE