MEDICARE: INTERSCOPE PATHOLOGY MEDICAL GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	05D0700248	CA

General Provider Information

NPI Number	:	1104830074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERSCOPE PATHOLOGY MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	30700 RUSSELL RANCH RD STE 250
Second Line	:
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91362-9507
Country	:	US
Telephone Number	:	818-992-7848
Fax Number	:	818-992-7748

Provider Business Practice Location Address
First Line	:	30700 RUSSELL RANCH RD SUITE 250, UNIT 235
Second Line	:
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91362-5907
Country	:	US
Telephone Number	:	818-992-7848
Fax Number	:	818-992-7748

Authorized Official
Title or Position	:	TREASUER/PRESIDENT
Name	:	DR. BRYAN T LIN
Credential	:	M.D.
Telephone Number	:	818-992-7848

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	01/05/2026

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