Basic Information
| Provider Information | |||||||||
| NPI: | 1265685036 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL PATHOLOGY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10076 | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914100076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788300 | ||||||||
| FaxNumber: | 8055783911 | ||||||||
| Practice Location | |||||||||
| Address1: | 3828 HUGHES AVE | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902322716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108367000 | ||||||||
| FaxNumber: | 3108153107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2008 | ||||||||
| LastUpdateDate: | 03/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | POWER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3108367000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | GR0016480 | 05 | CA | MEDICAID |