Provider Demographics
NPI:1003369380
Name:INTEGRATIVE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:INTEGRATIVE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SPIVAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-905-3331
Mailing Address - Street 1:2200 W 3RD ST
Mailing Address - Street 2:SUITE 120 A
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-1932
Mailing Address - Country:US
Mailing Address - Phone:310-905-3331
Mailing Address - Fax:310-453-2916
Practice Address - Street 1:2200 W 3RD ST
Practice Address - Street 2:SUITE 120 A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1932
Practice Address - Country:US
Practice Address - Phone:310-905-3331
Practice Address - Fax:310-453-2916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1136322086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty