1407111479 NPI number — PATHOLOGY, INC.

Table of content: DR. PERO KOMOZEC MD (NPI 1306839006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407111479 NPI number — PATHOLOGY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHOLOGY, 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:
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:
1407111479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19951 MARINER AVE
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
TORRANCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90503-1672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-769-0561
Provider Business Mailing Address Fax Number:
310-380-7165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
199 S ADDISON RD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
WOOD DALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60191-1929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-647-1082
Provider Business Practice Location Address Fax Number:
630-412-2010
Provider Enumeration Date:
07/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DIFRANCESCO
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
310-225-3147

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  14D2041305 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0092020 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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