Basic Information
| Provider Information | |||||||||
| NPI: | 1588749162 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAGNOSTIC PATHOLOGY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 C ST | ||||||||
| Address2: | #200E | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958163300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164476267 | ||||||||
| FaxNumber: | 9164470621 | ||||||||
| Practice Location | |||||||||
| Address1: | 5151 F ST | ||||||||
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| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958193223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164476267 | ||||||||
| FaxNumber: | 9164470621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 03/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | FINN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9164460424 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | CS7233 | 01 | CA | MEDICARE RAILROAD | OTHER | GR0010572 | 05 | CA | MEDICAID |