MEDICARE: INLE MEDICAL GROUP

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	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1316568348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INLE MEDICAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 573304
Second Line	:
City	:	TARZANA
State	:	CA
Zip	:	91357-3304
Country	:	US
Telephone Number	:	323-457-4541
Fax Number	:

Provider Business Practice Location Address
First Line	:	23586 CALABASAS RD STE 107
Second Line	:
City	:	CALABASAS
State	:	CA
Zip	:	91302-1334
Country	:	US
Telephone Number	:	323-457-4541
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JONATHAN PRINCE
Credential	:	MD
Telephone Number	:	646-528-3261

Provider Enumeration Date	:	04/30/2020
Last Update Date	:	04/30/2020

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Directions to “INLE MEDICAL GROUP ” Practice Location

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