Basic Information
| Provider Information | |||||||||
| NPI: | 1417982331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOASBERG | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 SANTA MONICA BLVD | ||||||||
| Address2: | STE 560W | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105827900 | ||||||||
| FaxNumber: | 3105827946 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 SANTA MONICA BLVD | ||||||||
| Address2: | STE 560W | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105827900 | ||||||||
| FaxNumber: | 3105827946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | G20643 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | G20643 | 01 | CA | MEDICAL LICENSE | OTHER | W15185A | 01 | CA | MEDICARE PTAN - FACILITY | OTHER | AB4426222 | 01 | CA | DEA | OTHER | W15185 | 01 | CA | MEDICARE PTAN - FACILITY | OTHER |