Basic Information
| Provider Information | |||||||||
| NPI: | 1386162949 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FACULTY PHYSICIANS AND SURGEONS OF LLUSM | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE NUMBER 54701 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900744701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584000 | ||||||||
| FaxNumber: | 9096514586 | ||||||||
| Practice Location | |||||||||
| Address1: | 197 E CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095582848 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2017 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | PEVERINI | ||||||||
| AuthorizedOfficialFirstName: | RICARDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9095587448 | ||||||||
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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 | 207RA0001X | N | 193200000X MULTI-SPECIALTY GROUP | 207RT0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Transplant Hepatology | 2080T0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Transplant Hepatology | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 364ST0500X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Transplantation | 204F00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Transplant Surgery |
No ID Information.