Healthcare Provider Details

I. General information

NPI: 1972624955
Provider Name (Legal Business Name): INNOVATIVE MEDICAL SOLUTIONS INC A MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14860 ROSCOE BLVD STE 200
PANORAMA CITY CA
91402-4683
US

IV. Provider business mailing address

PO BOX 15655
BEVERLY HILLS CA
90209-1655
US

V. Phone/Fax

Practice location:
  • Phone: 310-553-5203
  • Fax:
Mailing address:
  • Phone: 310-553-5203
  • Fax: 310-659-0933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License NumberG78454
License Number StateCA

VIII. Authorized Official

Name: DR. GLENN A MARSHAK
Title or Position: OWNER
Credential: M.D.
Phone: 310-553-5203