Basic Information
| Provider Information | |||||||||
| NPI: | 1588116321 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL PATHOLOGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1633 ERRINGER RD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930653583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788300 | ||||||||
| FaxNumber: | 8055783911 | ||||||||
| Practice Location | |||||||||
| Address1: | 13222 BLOOMFIELD AVE | ||||||||
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| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906503249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628634763 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2016 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | POWER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5628634763 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.