Basic Information
Provider Information | |||||||||
NPI: | 1275720377 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AHMC SAN GABRIEL VALLEY MEDICAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AHMC SAN GABREIL VALLEY MEDICAL CENTER, LP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 55 S RAYMOND AVE STE 105 | ||||||||
Address2: |   | ||||||||
City: | ALHAMBRA | ||||||||
State: | CA | ||||||||
PostalCode: | 91801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6264577938 | ||||||||
FaxNumber: | 6264577908 | ||||||||
Practice Location | |||||||||
Address1: | 438 W LAS TUNAS DR | ||||||||
Address2: |   | ||||||||
City: | SAN GABRIEL | ||||||||
State: | CA | ||||||||
PostalCode: | 917761216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6262895454 | ||||||||
FaxNumber: | 6262576555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2007 | ||||||||
LastUpdateDate: | 03/01/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARSH | ||||||||
AuthorizedOfficialFirstName: | LINDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6264577938 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 930000041 | CA | Y |   | Hospitals | General Acute Care Hospital |   |
No ID Information.