Provider Demographics
NPI:1972624955
Name:INNOVATIVE MEDICAL SOLUTIONS INC A MEDICAL GROUP
Entity type:Organization
Organization Name:INNOVATIVE MEDICAL SOLUTIONS INC A MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARSHAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-553-5203
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:310-553-5203
Mailing Address - Fax:310-659-0933
Practice Address - Street 1:14860 ROSCOE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-4683
Practice Address - Country:US
Practice Address - Phone:310-553-5203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78454207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13534BMedicare ID - Type UnspecifiedINTERNAL MEDICINE