Healthcare Provider Details

I. General information

NPI: 1912019423
Provider Name (Legal Business Name): EDWIN C. GLASS, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 WILSHIRE BLVD SUITE 810
SANTA MONICA CA
90403-4801
US

IV. Provider business mailing address

3271 ROSEWOOD AVE.
LOS ANGELES CA
90066-1735
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-9788
  • Fax: 310-264-1649
Mailing address:
  • Phone: 310-390-0761
  • Fax: 310-264-1649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207UN0903X
TaxonomyIn Vivo & In Vitro Nuclear Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberC35240
License Number StateCA

VIII. Authorized Official

Name: EDWIN C. GLASS
Title or Position: OWNER
Credential: M.D.
Phone: 310-390-0761