1598760985 NPI number — YOSEMITE PATHOLOGY MEDICAL GROUP, INC

Table of content: (NPI 1598760985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598760985 NPI number — YOSEMITE PATHOLOGY MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YOSEMITE PATHOLOGY MEDICAL GROUP, INC
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:
1598760985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 576768
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95357-6768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-577-1200
Provider Business Mailing Address Fax Number:
209-577-6517

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2625 COFFEE RD
Provider Second Line Business Practice Location Address:
STE S
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95355-2050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-577-1200
Provider Business Practice Location Address Fax Number:
209-577-6517
Provider Enumeration Date:
06/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COLLETTI
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
209-577-1200

Provider Taxonomy Codes

  • Taxonomy code: 207ZC0500X , with the licence number:  C32684 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZD0900X , with the licence number: C32684 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZF0201X , with the licence number: C32684 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZI0100X , with the licence number: C32684 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: C32684 , 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: GR0017742 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CP5083 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR001774A , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 690005510 . This is a "RAILROAD LAB" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0017744 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0017748 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0017741 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0017740 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0017745 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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