Provider Demographics
NPI:1750068086
Name:JSU MEDICAL, PC
Entity type:Organization
Organization Name:JSU MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:424-432-2304
Mailing Address - Street 1:1014 BROADWAY # 109
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2808
Mailing Address - Country:US
Mailing Address - Phone:424-432-2304
Mailing Address - Fax:
Practice Address - Street 1:2121 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2303
Practice Address - Country:US
Practice Address - Phone:424-432-2304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-28
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty