=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184799108
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER ALAN BARDWICK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2006
-----------------------------------------------------
Last Update Date | 01/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2811 WILSHIRE BLVD STE 550
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-828-4759
-----------------------------------------------------
Fax | 310-829-3947
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7235 MCCOOL AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90045-1229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-258-4484
-----------------------------------------------------
Fax | 310-943-3331
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | G34271
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------