Provider Demographics
NPI:1538351432
Name:VENICE NEWBURY MEDICAL CLINIC
Entity type:Organization
Organization Name:VENICE NEWBURY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CUTHBERT
Authorized Official - Middle Name:WESTON
Authorized Official - Last Name:PYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-290-6400
Mailing Address - Street 1:PO BOX 45407
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-0407
Mailing Address - Country:US
Mailing Address - Phone:323-290-6400
Mailing Address - Fax:323-290-6403
Practice Address - Street 1:3701 STOCKER ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-5108
Practice Address - Country:US
Practice Address - Phone:323-290-6400
Practice Address - Fax:323-290-6403
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CUTHBERT WESTON PYNE M.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-14
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01166ZOtherBLUE SHIELD
CA00A299581Medicaid
AKA25923Medicare UPIN