Basic Information
| Provider Information | |||||||||
| NPI: | 1154715845 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF SOUTHERN CALIFORNIA | ||||||||
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| OtherOrganizationName: | USC VERDUGO HILLS HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1510 SAN PABLO ST | ||||||||
| Address2: | HCC 600 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900335320 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1812 VERDUGO BLVD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912081409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187907100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2015 | ||||||||
| LastUpdateDate: | 03/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | JACKIEWICZ | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP & CEO, KECK MEDICINE OF USC | ||||||||
| AuthorizedOfficialTelephone: | 3234429775 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF SOUTHERN CALIFOR | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 930000173 | CA | Y | Hospitals | General Acute Care Hospital |
No ID Information.