Basic Information
Provider Information | |||||||||
NPI: | 1831188275 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GLENDALE ADVENTIST MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVENTIST HEALTH GLENDALE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1509 WILSON TER | ||||||||
Address2: |   | ||||||||
City: | GLENDALE | ||||||||
State: | CA | ||||||||
PostalCode: | 912064007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8184098000 | ||||||||
FaxNumber: | 8185465600 | ||||||||
Practice Location | |||||||||
Address1: | 1509 WILSON TER | ||||||||
Address2: |   | ||||||||
City: | GLENDALE | ||||||||
State: | CA | ||||||||
PostalCode: | 912064007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8184098000 | ||||||||
FaxNumber: | 8185465600 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/18/2005 | ||||||||
LastUpdateDate: | 08/16/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROBERTS | ||||||||
AuthorizedOfficialFirstName: | KEVIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8184098289 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 930000059 | CA | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | ZZT30067F | 05 | CA |   | MEDICAID | HSC30067F | 05 | CA |   | MEDICAID | ZZT40067F | 05 | CA |   | MEDICAID |