1003963216 NPI number — FOOTHILL UROLOGY ASSOCIATES

Table of content: (NPI 1003963216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003963216 NPI number — FOOTHILL UROLOGY ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOTHILL UROLOGY ASSOCIATES
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:
1003963216
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 S RAYMOND AVE
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91105-3278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-795-8454
Provider Business Mailing Address Fax Number:
626-795-5631

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 S RAYMOND AVE
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91105-3278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-795-8454
Provider Business Practice Location Address Fax Number:
626-795-5631
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SOTO
Authorized Official First Name:
TINA
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
626-795-8454

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CN2645 . This is a "MEDICARE RR" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ33990Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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