Basic Information
| Provider Information | |||||||||
| NPI: | 1770856809 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLENN MARTIN LIPTON, MD, AMC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13160 MINDANAO WAY STE 300 | ||||||||
| Address2: | |||||||||
| City: | MARINA DEL REY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902926393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105740400 | ||||||||
| FaxNumber: | 3105740371 | ||||||||
| Practice Location | |||||||||
| Address1: | 13160 MINDANAO WAY STE 300 | ||||||||
| Address2: | |||||||||
| City: | MARINA DEL REY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902926393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105740400 | ||||||||
| FaxNumber: | 3105740371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2012 | ||||||||
| LastUpdateDate: | 03/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | LIPTON | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
| AuthorizedOfficialMiddleName: | MARTIN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3105740400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | AZ32683 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.