Provider Demographics
NPI:1831707199
Name:PACIFIC INTEGRATIVE MEDICAL GROUP INC
Entity type:Organization
Organization Name:PACIFIC INTEGRATIVE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM SPARE HOLDER - VP
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:ANATOL
Authorized Official - Last Name:VASILEV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-393-2225
Mailing Address - Street 1:2232 SANTA MONICA BLVD # 101
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2312
Mailing Address - Country:US
Mailing Address - Phone:310-393-2225
Mailing Address - Fax:310-393-3321
Practice Address - Street 1:2232 SANTA MONICA BLVD # 101
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2312
Practice Address - Country:US
Practice Address - Phone:310-393-2225
Practice Address - Fax:310-393-3321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-22
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty