1336100759 NPI number — LA GOOD SAMARITAN PATHOLOGY MEDICAL GROUP, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336100759 NPI number — LA GOOD SAMARITAN PATHOLOGY MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA GOOD SAMARITAN 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:
6
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:
1336100759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15021 VENTURA BLVD.
Provider Second Line Business Mailing Address:
SUITE #771
Provider Business Mailing Address City Name:
SHERMAN OAKS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91403-2442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-981-0100
Provider Business Mailing Address Fax Number:
562-981-0600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2777 PACIFIC AVE
Provider Second Line Business Practice Location Address:
SUITE H201& I202
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90806-2625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-981-0100
Provider Business Practice Location Address Fax Number:
562-981-0600
Provider Enumeration Date:
03/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KHIAL
Authorized Official First Name:
SHAHRAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
818-216-0725

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: CLF0001448 , 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: ZZZ55908Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ED741A . This is a "PTAN ID #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: LAB02841F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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