Basic Information
Provider Information | |||||||||
NPI: | 1447356811 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARIN MEDICAL LABORATORIES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MARIN MEDICAL LABORATORIES MARIN GENERAL HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1615 HILL ROAD SUITE B | ||||||||
Address2: |   | ||||||||
City: | NOVATO | ||||||||
State: | CA | ||||||||
PostalCode: | 94947 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4152096983 | ||||||||
FaxNumber: | 4158980870 | ||||||||
Practice Location | |||||||||
Address1: | 250 BON AIR ROAD | ||||||||
Address2: |   | ||||||||
City: | GREENBRAE | ||||||||
State: | CA | ||||||||
PostalCode: | 94904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4159257174 | ||||||||
FaxNumber: | 4154617228 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2006 | ||||||||
LastUpdateDate: | 08/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRASAD | ||||||||
AuthorizedOfficialFirstName: | KEDAR | ||||||||
AuthorizedOfficialMiddleName: | CHE | ||||||||
AuthorizedOfficialTitleorPosition: | PATHOLOGIST | ||||||||
AuthorizedOfficialTelephone: | 4152096017 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 08/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | CLF316040 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | LAB00787F | 05 | CA |   | MEDICAID |