Basic Information
| Provider Information | |||||||||
| NPI: | 1639195175 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOS ANGELES DOCTORS CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LOS ANGELES METROPOLITAN MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2231 SOUTH WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237307300 | ||||||||
| FaxNumber: | 9497324671 | ||||||||
| Practice Location | |||||||||
| Address1: | 2231 SOUTH WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237307300 | ||||||||
| FaxNumber: | 9497324671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 07/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP/HOSPITAL CFO | ||||||||
| AuthorizedOfficialTelephone: | 3233776842 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | 953910448 | CA | N | Hospitals | Psychiatric Hospital | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSC30644F | 05 | CA | MEDICAID | HSP40644F | 05 | CA | MEDICAID | HSM30644F | 05 | CA | MEDICAID |