MEDICARE: WARREN S LINE JR MD A MEDICAL CORPORATION

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	207YX0007X	Plastic Surgery within the Head & Neck (Otolaryngology) Physician	G48150	CA
2	207Y00000X	Otolaryngology Physician	G48150	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851550974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WARREN S LINE JR MD A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	191 SOUTH BUENA VISTA STREET
Second Line	:	SUITE #320
City	:	BURBANK
State	:	CA
Zip	:	91505
Country	:	US
Telephone Number	:	818-763-7366
Fax Number	:	818-763-1809

Provider Business Practice Location Address
First Line	:	191 S BUENA VISTA ST
Second Line	:	SUITE #320
City	:	BURBANK
State	:	CA
Zip	:	91505
Country	:	US
Telephone Number	:	818-763-7366
Fax Number	:	818-763-1809

Authorized Official
Title or Position	:	PRESIDENT
Name	:	WARREN SCOTT LINE JR.
Credential	:	MD
Telephone Number	:	818-763-7366

Provider Enumeration Date	:	06/04/2008
Last Update Date	:	06/04/2008

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