Basic Information
| Provider Information | |||||||||
| NPI: | 1679602742 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTEREY PATHOLOGISTS, A MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23625 HOLMAN HWY | ||||||||
| Address2: | PATHOLOGY | ||||||||
| City: | MONTEREY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939405902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316245311 | ||||||||
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| Practice Location | |||||||||
| Address1: | 23625 HOLMAN HWY | ||||||||
| Address2: | PATHOLOGY | ||||||||
| City: | MONTEREY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939405902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316245311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8316245311 | ||||||||
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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 | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ02530Z | 01 | CA | BLUE SHIELD | OTHER |