Basic Information
| Provider Information | |||||||||
| NPI: | 1073544714 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE ANGELES CLINIC AND RESEARCH INSTITUTE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 SANTA MONICA BLVD | ||||||||
| Address2: | SUITE 560W | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105827900 | ||||||||
| FaxNumber: | 3105827894 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 SANTA MONICA BLVD | ||||||||
| Address2: | SUITE 560W | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105827900 | ||||||||
| FaxNumber: | 3105827894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 09/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | QUINN | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3105827988 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0902X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | W15185A | 01 | CA | MEDICARE PTAN - FACILITY | OTHER | W15185 | 01 | CA | MEDICARE PTAN - FACILITY | OTHER |