Provider Demographics
NPI:1073636817
Name:SOBOL ORTHOPEDIC MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SOBOL ORTHOPEDIC MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:SOBOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-649-5894
Mailing Address - Street 1:8618 S SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-4005
Mailing Address - Country:US
Mailing Address - Phone:310-649-5894
Mailing Address - Fax:310-649-5898
Practice Address - Street 1:8618 S SEPULVEDA BLVD
Practice Address - Street 2:STE. 130
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-4005
Practice Address - Country:US
Practice Address - Phone:310-649-5894
Practice Address - Fax:310-649-1094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
G42254207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A48883Medicare UPIN
G42254Medicare ID - Type Unspecified