1316970932 NPI number — CMCLA PATHOLOGY MEDICAL GROUP

Table of content: (NPI 1316970932)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316970932 NPI number — CMCLA PATHOLOGY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CMCLA PATHOLOGY MEDICAL GROUP
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:
1316970932
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5700 SOUTHWYCK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43614-1509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-288-8325
Provider Business Mailing Address Fax Number:
419-866-5453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 SOUTH GRAND AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90015-3010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-742-5793
Provider Business Practice Location Address Fax Number:
419-866-5453
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NACHAZEL
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PATHOLOGIST/OWNER
Authorized Official Telephone Number:
213-742-5793

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: GR0059120 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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