Provider Demographics
NPI:1699906453
Name:VITAL SOLUTIONS MEDICAL GROUP
Entity type:Organization
Organization Name:VITAL SOLUTIONS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-914-9150
Mailing Address - Street 1:PO BOX 15655
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90209-1655
Mailing Address - Country:US
Mailing Address - Phone:310-914-9150
Mailing Address - Fax:310-914-9705
Practice Address - Street 1:6000 SAN VICENTE BLVD FL 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4404
Practice Address - Country:US
Practice Address - Phone:310-914-9150
Practice Address - Fax:310-914-9705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF91203Medicare UPIN