Basic Information
| Provider Information | |||||||||
| NPI: | 1952546616 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF SOUTHERN CALIFORNIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | KECK HOSPITAL OF USC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 SAN PABLO ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900339857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234428444 | ||||||||
| FaxNumber: | 3234425257 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 SAN PABLO STREET | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900339857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234428500 | ||||||||
| FaxNumber: | 3234428727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2008 | ||||||||
| LastUpdateDate: | 02/11/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKIEWICZ | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP & CEO, KECK MEDICINE OF USC | ||||||||
| AuthorizedOfficialTelephone: | 3234429775 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF SOUTHERN CALIFOR | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 930000459 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSC30696G | 05 | CA | MEDICAID | HSP40696G | 05 | CA | MEDICAID |