1871646679 NPI number — SCOTT C LEDERHAUS MD & LEW B DISNEY MD PRT LEDERHAUS SCOTT C GEN PTR

Table of content: (NPI 1871646679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871646679 NPI number — SCOTT C LEDERHAUS MD & LEW B DISNEY MD PRT LEDERHAUS SCOTT C GEN PTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCOTT C LEDERHAUS MD & LEW B DISNEY MD PRT LEDERHAUS SCOTT C GEN PTR
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:
INLAND NEUROSURGERY INSTITUTE
Provider Other Organization Name Type Code:
3
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:
1871646679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
255 E BONITA AVE
Provider Second Line Business Mailing Address:
BLDG #9
Provider Business Mailing Address City Name:
POMONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91767-1923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-450-0369
Provider Business Mailing Address Fax Number:
909-450-0366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
255 E BONITA AVE
Provider Second Line Business Practice Location Address:
BLDG #9
Provider Business Practice Location Address City Name:
POMONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91767-1923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-450-0369
Provider Business Practice Location Address Fax Number:
909-450-0366
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PEREZ
Authorized Official First Name:
ANNA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
909-450-0369

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CB216289 . This is a "MEDICARE SOUTH CUTLER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A986190 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CA123795 . This is a "MEDICARE NORTH CUTLER" identifier . This identifiers is of the category "OTHER".
  • Identifier: GR0099730 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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