Provider Demographics
NPI:1801045778
Name:L.E.V. MEDICAL GROUP, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:L.E.V. MEDICAL GROUP, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:PRESTIGE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VLAD
Authorized Official - Middle Name:
Authorized Official - Last Name:NUSINOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-623-9222
Mailing Address - Street 1:7855 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-5344
Mailing Address - Country:US
Mailing Address - Phone:310-623-9222
Mailing Address - Fax:310-921-5623
Practice Address - Street 1:7855 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-5344
Practice Address - Country:US
Practice Address - Phone:310-623-9222
Practice Address - Fax:310-921-5623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-15
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92996207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92996Medicare UPIN