Provider Demographics
NPI:1104830074
Name:INTERSCOPE PATHOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:INTERSCOPE PATHOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASUER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-992-7848
Mailing Address - Street 1:21114 VANOWEN ST
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-2821
Mailing Address - Country:US
Mailing Address - Phone:818-992-7848
Mailing Address - Fax:818-992-7748
Practice Address - Street 1:18321 CLARK ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3501
Practice Address - Country:US
Practice Address - Phone:818-708-5528
Practice Address - Fax:818-708-5546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D0700248174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHW10026BMedicare ID - Type UnspecifiedMEDICARE PROVIDER #
CA05D0700248Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
CAW11026Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
CAHW11026CMedicare ID - Type UnspecifiedMEDICARE PROVIDER #