Basic Information
Provider Information | |||||||||
NPI: | 1932342854 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALTA EAST BAY PATHOLOGY INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1633 ERRINGER RD | ||||||||
Address2: | 1ST FLOOR | ||||||||
City: | SIMI VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 930653583 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055788300 | ||||||||
FaxNumber: | 8055783911 | ||||||||
Practice Location | |||||||||
Address1: | 3300 WEBSTER ST | ||||||||
Address2: | #1201 | ||||||||
City: | OAKLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 946093117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055788300 | ||||||||
FaxNumber: | 8055783911 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2009 | ||||||||
LastUpdateDate: | 04/08/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SHAIEB | ||||||||
AuthorizedOfficialFirstName: | ANNETTE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8055788300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | 05D1082851 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | 05D1082851 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.