1083712525 NPI number — ST FRANCIS PATHOLOGY MEDICAL GROUP

Table of content: (NPI 1083712525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083712525 NPI number — ST FRANCIS PATHOLOGY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST FRANCIS PATHOLOGY MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083712525
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3630 E IMPERIAL HWY
Provider Second Line Business Mailing Address:
DEPARTMENT OF PATHOLOGY
Provider Business Mailing Address City Name:
LYNWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90262-2609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-900-8615
Provider Business Mailing Address Fax Number:
310-763-3907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5856 CORPORATE AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CYPRESS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90630-4754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-236-4000
Provider Business Practice Location Address Fax Number:
714-236-4006
Provider Enumeration Date:
09/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SCHNEIDER
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
310-900-8883

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  G30735 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ47547Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0067990 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".