Basic Information
| Provider Information | |||||||||
| NPI: | 1922018977 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | USC HEAD & NECK GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1520 SAN PABLO ST | ||||||||
| Address2: | SUITE 4600 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900335310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234425790 | ||||||||
| FaxNumber: | 3234425820 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 SAN PABLO ST | ||||||||
| Address2: | SUITE 4600 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900335310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234425790 | ||||||||
| FaxNumber: | 3234425820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | UDEN | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE PLAN ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3234425827 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0007X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck |
ID Information
| ID | Type | State | Issuer | Description | GR0056450 | 05 | CA | MEDICAID |