1912991597 NPI number — PATHOLOGY ASSOCIATES OF SOUTHERN CALIFORNIA

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 1912991597 NPI number — PATHOLOGY ASSOCIATES OF SOUTHERN CALIFORNIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHOLOGY ASSOCIATES OF SOUTHERN CALIFORNIA
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:
1912991597
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2219 W OLIVE AVE # 219
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURBANK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91506-2625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-847-6052
Provider Business Mailing Address Fax Number:
323-784-2904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 S BUENA VISTA ST
Provider Second Line Business Practice Location Address:
DEPT OF PATHOLOGY
Provider Business Practice Location Address City Name:
BURBANK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91505-4809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-847-6052
Provider Business Practice Location Address Fax Number:
818-847-6029
Provider Enumeration Date:
09/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ESTEBAN
Authorized Official First Name:
JOSE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
818-847-6052

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0011010 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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