Basic Information
| Provider Information | |||||||||
| NPI: | 1588917322 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA INTERVENTIONAL MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 BUTTERFIELD RD. | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307252700 | ||||||||
| FaxNumber: | 6307252783 | ||||||||
| Practice Location | |||||||||
| Address1: | 11601 WILSHIRE BLVD | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 99025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307252737 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2012 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | WORTHINGTON-KIRSCH | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6307252700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 202K00000X | G88795 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Phlebology |
No ID Information.