Basic Information
| Provider Information | |||||||||
| NPI: | 1780974790 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAC-USC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N. STATE ST., IRD 620, | ||||||||
| Address2: | LAC -USC MED CENTER | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232267556 | ||||||||
| FaxNumber: | 3232262657 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N. STATE ST., IRD 620, | ||||||||
| Address2: | LAC -USC MED CENTER, | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232267556 | ||||||||
| FaxNumber: | 3232262657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 04/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | BEN-ARI | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3232267556 | ||||||||
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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 | 207R00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 251V00000X | N | Agencies | Voluntary or Charitable | 261Q00000X | A116505 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | 281P00000X | A116505 | CA | N | Hospitals | Chronic Disease Hospital | 302R00000X | A116505 | CA | N | Managed Care Organizations | Health Maintenance Organization | 282N00000X | A116505 | CA | Y | Hospitals | General Acute Care Hospital |
No ID Information.