Basic Information
| Provider Information | |||||||||
| NPI: | 1982673398 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANALYTIC PATHOLOGY MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10076 | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914100076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788950 | ||||||||
| FaxNumber: | 8055788950 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 ROSS AVE | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922434306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197404492 | ||||||||
| FaxNumber: | 6197404418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 07/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | CARRY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7603397100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | GR0092920 | 01 | CA | DHS GROUP ID | OTHER | ZZZ46835Z | 01 | CA | BLUE SHIELD GROUP ID | OTHER |