Healthcare Provider Details

I. General information

NPI: 1891876702
Provider Name (Legal Business Name): INTEGRATED SPECIALTY MEDICAL ASSOCIATES IPA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 W 190TH ST SUITE 410
GARDENA CA
90248-4319
US

IV. Provider business mailing address

1515 W 190TH ST SUITE 410
GARDENA CA
90248-4319
US

V. Phone/Fax

Practice location:
  • Phone: 310-538-1239
  • Fax: 310-538-0929
Mailing address:
  • Phone: 310-538-1239
  • Fax: 310-538-0929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. JACK RUBIN
Title or Position: TREASURER
Credential: M.D.
Phone: 310-538-1239