=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104830074
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERSCOPE PATHOLOGY MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2006
-----------------------------------------------------
Last Update Date | 01/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30700 RUSSELL RANCH RD SUITE 250, UNIT 235
-----------------------------------------------------
City | WESTLAKE VILLAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91362-5907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-992-7848
-----------------------------------------------------
Fax | 818-992-7748
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30700 RUSSELL RANCH RD STE 250
-----------------------------------------------------
City | WESTLAKE VILLAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91362-9507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-992-7848
-----------------------------------------------------
Fax | 818-992-7748
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREASUER/PRESIDENT
-----------------------------------------------------
Name | DR. BRYAN T LIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 818-992-7848
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | 05D0700248
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------