Provider Demographics
NPI:1396027892
Name:GERALD M. POHOST, MD, INC.
Entity Type:Organization
Organization Name:GERALD M. POHOST, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:POHOST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-409-3501
Mailing Address - Street 1:2200 N MAYFAIR RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2252
Mailing Address - Country:US
Mailing Address - Phone:414-258-9511
Mailing Address - Fax:414-607-3946
Practice Address - Street 1:1505 WILSON TER
Practice Address - Street 2:SUITE 150
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4071
Practice Address - Country:US
Practice Address - Phone:818-409-3501
Practice Address - Fax:818-956-7680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADS3096OtherRR MEDICARE
CAZZZ68624YOtherBLUE SHIELD
CAZZZ68624YOtherBLUE SHIELD