Provider Demographics
NPI:1588917322
Name:CALIFORNIA INTERVENTIONAL MEDICAL GROUP
Entity type:Organization
Organization Name:CALIFORNIA INTERVENTIONAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WORTHINGTON-KIRSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-725-2700
Mailing Address - Street 1:1901 BUTTERFIELD RD.
Mailing Address - Street 2:SUITE 220
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1279
Mailing Address - Country:US
Mailing Address - Phone:630-725-2700
Mailing Address - Fax:630-725-2783
Practice Address - Street 1:11601 WILSHIRE BLVD
Practice Address - Street 2:5TH FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:99025
Practice Address - Country:US
Practice Address - Phone:630-725-2737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG88795202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Multi-Specialty