Basic Information
| Provider Information | |||||||||
| NPI: | 1306915764 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STEVEN P. BLEIWEISS MD, INC | ||||||||
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| OtherOrganizationName: | KENNEDY SURGICAL PATHOLOGY MEDICAL ASSOCIATES, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 6015-0015 | ||||||||
| Address2: | |||||||||
| City: | CYPRESS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906300015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142364000 | ||||||||
| FaxNumber: | 7142364006 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 WATERMAN | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098814522 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 07/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | BLEIWEISS | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | MD/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9098816711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | G20642 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ02881Z | 01 | CA | BLUE SHIELD | OTHER | GR0088961 | 05 | CA | MEDICAID |