Basic Information
| Provider Information | |||||||||
| NPI: | 1932150315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PULSIPHER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4650 W SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233612546 | ||||||||
| FaxNumber: | 3233618068 | ||||||||
| Practice Location | |||||||||
| Address1: | 4650 W SUNSET BLVD | ||||||||
| Address2: | MAIL STOP #54 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233612546 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 357548-1205 | UT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 357548-1205 | UT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 208000000X | 357548-1205 | UT | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0207X | 357548-1205 | UT | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 904 | 01 | UNIVERSITY HEALTH PLANS # | OTHER | 0031620 | 05 | MT | MEDICAID | 003038700 | 05 | ID | MEDICAID | 61589039 | 05 | NM | MEDICAID | 274044 | 01 | DMBA # | OTHER | MD265UT | 05 | AK | MEDICAID | QM0000049131 | 01 | ALTIUS # | OTHER | 60365 | 01 | PEHP # | OTHER |