Basic Information
| Provider Information | |||||||||
| NPI: | 1205371630 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC TRAUMA ASSOCIATES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 E GLENARM ST | ||||||||
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| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911053418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267684415 | ||||||||
| FaxNumber: | 6264030321 | ||||||||
| Practice Location | |||||||||
| Address1: | 11550 INDIAN HILLS RD STE 310 | ||||||||
| Address2: | |||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913451203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188984900 | ||||||||
| FaxNumber: | 8188984990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2016 | ||||||||
| LastUpdateDate: | 12/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | BRICKER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3109415059 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | 90638 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 90638 | 01 | CA | CA MED LICENSE | OTHER |