Basic Information
| Provider Information | |||||||||
| NPI: | 1891798765 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | USC PPA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1520 SAN PABLO ST | ||||||||
| Address2: | STE 4100 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900335316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234426000 | ||||||||
| FaxNumber: | 3234426001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 SAN PABLO ST | ||||||||
| Address2: | STE 4100 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900335316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234426000 | ||||||||
| FaxNumber: | 3234426001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BANGARA | ||||||||
| AuthorizedOfficialFirstName: | SURESH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | C.E.O. | ||||||||
| AuthorizedOfficialTelephone: | 3234426000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY5097 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.