Provider Demographics
NPI:1033244611
Name:ROSALIND G. PALLIVATHUCAL MD INC.
Entity Type:Organization
Organization Name:ROSALIND G. PALLIVATHUCAL MD INC.
Other - Org Name:CLINICA MARIA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSALIND
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:PALLIVATHUCAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-357-1000
Mailing Address - Street 1:8100 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-2469
Mailing Address - Country:US
Mailing Address - Phone:323-357-1000
Mailing Address - Fax:323-357-1001
Practice Address - Street 1:8100 CALIFORNIA AVE
Practice Address - Street 2:SUITE K
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-2469
Practice Address - Country:US
Practice Address - Phone:323-357-1000
Practice Address - Fax:323-357-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43918207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A43918Medicaid
CA0A43918Medicaid
CAA43918Medicare ID - Type Unspecified