Basic Information
| Provider Information | |||||||||
| NPI: | 1417023409 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PATHOLOGY & LABORATORY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5856 CORPORATE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CYPRESS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906304754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142364000 | ||||||||
| FaxNumber: | 7142364006 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 W BEVERLY BLVD | ||||||||
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| City: | MONTEBELLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906404308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237254211 | ||||||||
| FaxNumber: | 3238892406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 06/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | ORLANDO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3237254211 | ||||||||
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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 | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | GR0066850 | 05 | CA | MEDICAID | ZZZ02790Z | 01 | CA | BLUE SHIELD | OTHER |