1568595684 NPI number — UNIVERSITY OF SOUTHERN CALIFORNIA

Table of content: (NPI 1568595684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568595684 NPI number — UNIVERSITY OF SOUTHERN CALIFORNIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY 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:
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:
1568595684
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 513199
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90051-1199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-865-0563
Provider Business Mailing Address Fax Number:
323-865-0122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1441 EASTLAKE AVENUE
Provider Second Line Business Practice Location Address:
ROOM 5409
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-865-0563
Provider Business Practice Location Address Fax Number:
323-865-0122
Provider Enumeration Date:
03/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DICKEY
Authorized Official First Name:
TODD
Authorized Official Middle Name:
Authorized Official Title or Position:
SR VP - ADMINISTRATION
Authorized Official Telephone Number:
213-740-8184

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  05D0684670 , 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: LAB84670F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: W7801B . This is a "MEDICARE CODE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ09704Z . This is a "BLUE SHIELD CODE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CLF315998 . This is a "STATE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 690000015 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05D0684670 . This is a "MEDICARE ID - UNSPECIFIED" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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