MEDICARE: EDWIN C. GLASS, M.D., 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	207UN0901X	Nuclear Cardiology Physician
2	207UN0902X	Nuclear Imaging & Therapy Physician
3	207UN0903X	In Vivo & In Vitro Nuclear Medicine Physician
4	207U00000X	Nuclear Medicine Physician	C35240	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00C352400	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1912019423
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDWIN C. GLASS, M.D., INC.

Provider Business Mailing Address
First Line	:	3271 ROSEWOOD AVE.
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-1735
Country	:	US
Telephone Number	:	310-390-0761
Fax Number	:	310-264-1649

Provider Business Practice Location Address
First Line	:	2811 WILSHIRE BLVD
Second Line	:	SUITE 810
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-4801
Country	:	US
Telephone Number	:	310-829-9788
Fax Number	:	310-264-1649

Authorized Official
Title or Position	:	OWNER
Name	:	EDWIN C. GLASS
Credential	:	M.D.
Telephone Number	:	310-390-0761

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/13/2007

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Directions to “EDWIN C. GLASS, M.D., INC. ” Practice Location

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