Provider Demographics
NPI:1720220981
Name:INDIMED CORPORATION
Entity Type:Organization
Organization Name:INDIMED CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:G
Authorized Official - Last Name:TAPPAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-602-1160
Mailing Address - Street 1:17620 SHERMAN WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-3527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17620 SHERMAN WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3527
Practice Address - Country:US
Practice Address - Phone:818-602-1160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23884207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABT132AMedicare PIN