Basic Information
| Provider Information | |||||||||
| NPI: | 1760637896 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN LUIS HOSPITALISTS A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1464 | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934061464 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1911 JOHNSON AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934014197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055435353 | ||||||||
| FaxNumber: | 8055426661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2008 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | KELLER | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8055038422 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ56478Y | 01 | CA | BLUE SHIELD GROUP NUMBER 2 (1911 JOHNSON) | OTHER | 1218 | 01 | CA | CMSP PROVIDER NUMBER | OTHER |