Healthcare Provider Details

I. General information

NPI: 1386087633
Provider Name (Legal Business Name): INTERACTIVE HEALTHCARE MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 04/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1762 WESTWOOD BLVD 300
LOS ANGELES CA
90024-5632
US

IV. Provider business mailing address

1762 WESTWOOD BLVD 300
LOS ANGELES CA
90024-5632
US

V. Phone/Fax

Practice location:
  • Phone: 310-441-2000
  • Fax: 310-441-2020
Mailing address:
  • Phone: 310-441-2000
  • Fax: 310-441-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberA101434
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA101434
License Number StateCA

VIII. Authorized Official

Name: DR. MICHAEL S BROUKHIM
Title or Position: PRESIDENT
Credential: MD
Phone: 310-441-2000