MEDICARE: SHALOM PAIN TREATMENT MEDICAL CENTER 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	207LP2900X	Pain Medicine (Anesthesiology) Physician	A50982	CA
2	207L00000X	Anesthesiology Physician	A50982	CA

General Provider Information

NPI Number	:	1598726531
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHALOM PAIN TREATMENT MEDICAL CENTER INC

Provider Business Mailing Address
First Line	:	PO BOX 16713
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90209-2713
Country	:	US
Telephone Number	:	818-497-3797
Fax Number	:	310-860-1326

Provider Business Practice Location Address
First Line	:	1016 S ROBERTSON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-1505
Country	:	US
Telephone Number	:	818-497-3797
Fax Number	:	310-860-1326

Authorized Official
Title or Position	:	DIRECT OWNER
Name	:	KOUROSH NOORMAND
Credential	:	M.D.
Telephone Number	:	818-497-3797

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	05/24/2016

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