Basic Information
Provider Information | |||||||||
NPI: | 1831460146 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | APEX PATHOLOGY MEDICAL GROUP INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 10076 | ||||||||
Address2: |   | ||||||||
City: | VAN NUYS | ||||||||
State: | CA | ||||||||
PostalCode: | 914100076 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055788300 | ||||||||
FaxNumber: | 8055783911 | ||||||||
Practice Location | |||||||||
Address1: | 1117 E DEVONSHIRE AVE | ||||||||
Address2: | DEPARTMENT OF PATHOLOGY | ||||||||
City: | HEMET | ||||||||
State: | CA | ||||||||
PostalCode: | 925433083 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9519256318 | ||||||||
FaxNumber: | 9517666408 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/18/2012 | ||||||||
LastUpdateDate: | 01/18/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAO | ||||||||
AuthorizedOfficialFirstName: | VINAY | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 9516403027 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | 05D0573549 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | 05D0573549 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.