Provider Demographics
NPI:1912019423
Name:EDWIN C. GLASS, M.D., INC.
Entity Type:Organization
Organization Name:EDWIN C. GLASS, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-390-0761
Mailing Address - Street 1:3271 ROSEWOOD AVE.
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-1735
Mailing Address - Country:US
Mailing Address - Phone:310-390-0761
Mailing Address - Fax:310-264-1649
Practice Address - Street 1:2811 WILSHIRE BLVD
Practice Address - Street 2:SUITE 810
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4801
Practice Address - Country:US
Practice Address - Phone:310-829-9788
Practice Address - Fax:310-264-1649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC35240207U00000X
207UN0901X, 207UN0902X, 207UN0903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Single Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Single Specialty
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Single Specialty
No207UN0903XAllopathic & Osteopathic PhysiciansNuclear MedicineIn Vivo & In Vitro Nuclear MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C352400OtherBLUE SHIELD
CA00C352400OtherBLUE SHIELD
CAC35240AMedicare ID - Type Unspecified
CA00C352400Medicare ID - Type Unspecified