Basic Information
| Provider Information | |||||||||
| NPI: | 1548354426 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DALY CITY PATHOLOGY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29471 | ||||||||
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| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631267471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888438475 | ||||||||
| FaxNumber: | 8444103798 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 SULLIVAN AVE | ||||||||
| Address2: | |||||||||
| City: | DALY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6509916587 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | GERARD | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6509916568 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207U00000X | CLF798 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | 207ZP0102X | CLF798 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | GR0010990 | 05 | CA | MEDICAID |