Healthcare Provider Details

I. General information

NPI: 1326378571
Provider Name (Legal Business Name): GORLITSKY, STEIN & HERNANDEZ MEDICAL GROUP, CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2010
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD., STE #680W
SANTA MONICA CA
90404-2102
US

IV. Provider business mailing address

2001 SANTA MONICA BLVD., STE #680W
SANTA MONICA CA
90404-2102
US

V. Phone/Fax

Practice location:
  • Phone: 310-442-2113
  • Fax: 310-442-9596
Mailing address:
  • Phone: 310-442-2113
  • Fax: 310-442-9596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GLENN A GORLITSKY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-453-0419