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General NPI Number Information
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NPI Number | 1013131796
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Entity Type | Organization
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Legal Business Name | INNOVATIVE DIAGNOSTIC MEDICAL GROUP
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 12/16/2010
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Provider Practice Location Address
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Address Line | 1801 CENTURY PARK EAST SUITE 1040
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City | LOS ANGELES
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State | CA
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Zip | 90067
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Country | US
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Telephone | 310-553-7980
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Fax | 310-943-3279
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Provider Business Mailing Address
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Address Line | 1801 CENTURY PARK EAST SUITE 1040
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City | LOS ANGELES
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State | CA
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Zip | 90067
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Country | US
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Telephone | 310-553-7980
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Fax | 310-943-3279
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Authorized Official
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Title or Position | MEDICAL DIRECTOR/OWNER
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Name | SEAN ATAEE
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Credential | M.D.
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Telephone | 310-553-7960
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | A106704
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 293D00000X
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Taxonomy Name | Physiological Laboratory
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License Number | A44107
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License Number State | CA
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