1861535718 NPI number — PATHOLOGY ASSOCIATES OF ANAHEIM A PROFESSIONAL MEDICAL CORPORATION

Table of content: (NPI 1861535718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861535718 NPI number — PATHOLOGY ASSOCIATES OF ANAHEIM A PROFESSIONAL MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHOLOGY ASSOCIATES OF ANAHEIM A PROFESSIONAL MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
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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:
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NPI Number Information

NPI Number:
1861535718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 W LA PALMA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANAHEIM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92801-2804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-999-6075
Provider Business Mailing Address Fax Number:
714-999-3822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 W LA PALMA AVE
Provider Second Line Business Practice Location Address:
AMMC - DEPT. OF PATHOLOGY
Provider Business Practice Location Address City Name:
ANAHEIM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92801-2804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-999-6075
Provider Business Practice Location Address Fax Number:
714-999-3822
Provider Enumeration Date:
02/14/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WELSH
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-719-2148

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  G50440 , 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: ZZZ69658Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0104860 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".