1588917322 NPI number — CALIFORNIA INTERVENTIONAL MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588917322 NPI number — CALIFORNIA INTERVENTIONAL MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CALIFORNIA INTERVENTIONAL MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588917322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 BUTTERFIELD RD.
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
DOWNERS GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60515-1279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-725-2700
Provider Business Mailing Address Fax Number:
630-725-2783

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11601 WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
5TH FLOOR
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
99025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-725-2737
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WORTHINGTON-KIRSCH
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
630-725-2700

Provider Taxonomy Codes

  • Taxonomy code: 202K00000X , with the licence number:  G88795 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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