Provider Demographics
NPI:1265685036
Name:MEMORIAL PATHOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:MEMORIAL PATHOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:POWER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-836-7000
Mailing Address - Street 1:PO BOX 10076
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91410-0076
Mailing Address - Country:US
Mailing Address - Phone:805-578-8300
Mailing Address - Fax:805-578-3911
Practice Address - Street 1:3828 HUGHES AVE
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2716
Practice Address - Country:US
Practice Address - Phone:310-836-7000
Practice Address - Fax:310-815-3107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-24
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0016480Medicaid
CAGR0016480Medicaid