Basic Information
Provider Information | |||||||||
NPI: | 1811907512 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LODI MEMORIAL HOSPITAL ASSOCIATION INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LODI MEMORIAL HOSPITAL OB CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 884577 | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900884577 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2093343411 | ||||||||
FaxNumber: | 2093397659 | ||||||||
Practice Location | |||||||||
Address1: | 2415 W VINE ST | ||||||||
Address2: | SUITE 103 | ||||||||
City: | LODI | ||||||||
State: | CA | ||||||||
PostalCode: | 952423731 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2093333030 | ||||||||
FaxNumber: | 2093397659 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2006 | ||||||||
LastUpdateDate: | 01/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WHITNEY | ||||||||
AuthorizedOfficialFirstName: | JASON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | FINANCE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2093397477 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LODI MEMORIAL HOSPITAL ASSOCIATION INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | N |   | Hospitals | General Acute Care Hospital |   | 261Q00000X | 030000056 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | ZZZ78517Z | 05 | CA |   | MEDICAID | ZZZ78517Z | 01 | CA | BLUE SHIELD | OTHER |