1972709376 NPI number — THOMAS L. VANDER LAAN, M.D., AMC

Table of content: (NPI 1972709376)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972709376 NPI number — THOMAS L. VANDER LAAN, M.D., AMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THOMAS L. VANDER LAAN, M.D., AMC
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:
1972709376
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 BELLEFONTAINE ST
Provider Second Line Business Mailing Address:
STE 303
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91105-3132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-793-4136
Provider Business Mailing Address Fax Number:
626-793-8279

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 BELLEFONTAINE ST
Provider Second Line Business Practice Location Address:
STE 303
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91105-3132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-793-4136
Provider Business Practice Location Address Fax Number:
626-793-8279
Provider Enumeration Date:
06/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VANDER LAAN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR-PHYSICIAN
Authorized Official Telephone Number:
626-793-4136

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G44443 , 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: W1289 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G444430 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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