Basic Information
| Provider Information | |||||||||
| NPI: | 1144326471 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARIN MEDICAL LABORATORIES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MARIN MEDICAL LABORATORIES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 HILL ROAD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158987649 | ||||||||
| FaxNumber: | 4158980870 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 HILL ROAD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158987649 | ||||||||
| FaxNumber: | 4158980870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 10/23/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WASSERSTEIN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 4159257174 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | CLF789 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 05D0663150 | 01 | CLIA | OTHER | LAB63150F | 05 | CA | MEDICAID | CLF789 | 01 | STATE LICENSE | OTHER |