MEDICARE: INNOVATIVE PAIN AND SPINE PHYSICIANS

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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1043593098	OTHER		NPI
2	CB228966	OTHER		PTAN

General Provider Information

NPI Number	:	1174929376
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE PAIN AND SPINE PHYSICIANS

Provider Business Mailing Address
First Line	:	4418 VINELAND AVE STE 218
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91602-2159
Country	:	US
Telephone Number	:	818-621-0019
Fax Number	:	818-671-5556

Provider Business Practice Location Address
First Line	:	4418 VINELAND AVE STE 218
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91602-2159
Country	:	US
Telephone Number	:	818-621-0019
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MATTHEW S ROOT
Credential	:	D.O.
Telephone Number	:	818-621-0019

Provider Enumeration Date	:	11/15/2014
Last Update Date	:	09/29/2019

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Directions to “INNOVATIVE PAIN AND SPINE PHYSICIANS ” Practice Location

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