MEDICARE: IPB MEDICAL DIAGNOSTIC, 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	293D00000X	Physiological Laboratory

General Provider Information

NPI Number	:	1144391947
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IPB MEDICAL DIAGNOSTIC, INC.

Provider Business Mailing Address
First Line	:	PO BOX 9155
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90295-1555
Country	:	US
Telephone Number	:	310-500-6410
Fax Number	:

Provider Business Practice Location Address
First Line	:	8939 S SEPULVEDA BL
Second Line	:	SUITE 504
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-3631
Country	:	US
Telephone Number	:	310-649-5264
Fax Number	:	310-822-1062

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PAVEL BAIMKIN
Credential	:
Telephone Number	:	310-500-6410

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	08/22/2020

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