Provider Demographics
NPI:1316003635
Name:EDWARD L. RICEBERG, M.D., INC.
Entity Type:Organization
Organization Name:EDWARD L. RICEBERG, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:RICEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-550-8028
Mailing Address - Street 1:9400 BRIGHTON WAY
Mailing Address - Street 2:SUITE #410
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4711
Mailing Address - Country:US
Mailing Address - Phone:310-550-8028
Mailing Address - Fax:310-278-1570
Practice Address - Street 1:9400 BRIGHTON WAY
Practice Address - Street 2:SUITE #410
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4711
Practice Address - Country:US
Practice Address - Phone:310-550-8028
Practice Address - Fax:310-278-1570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22329207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA23020Medicare UPIN