=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265908966
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANCER INSTITUTE OF AMERICA MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2018
-----------------------------------------------------
Last Update Date | 06/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 416 N BEDFORD DR STE 100
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90210-4308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-993-4679
-----------------------------------------------------
Fax | 424-324-3880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 416 N BEDFORD DR STE 100
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90210-4308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-993-4679
-----------------------------------------------------
Fax | 424-324-3880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CRISTIANO BONETI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 305-951-6543
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------