Provider Demographics
NPI:1407802069
Name:PATHWAY MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:PATHWAY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:HASSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALKHOULI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-379-3221
Mailing Address - Street 1:PO BOX 2989
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-1989
Mailing Address - Country:US
Mailing Address - Phone:714-636-9850
Mailing Address - Fax:714-636-1248
Practice Address - Street 1:12462 BROOKHURST ST
Practice Address - Street 2:#A&B
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4759
Practice Address - Country:US
Practice Address - Phone:714-636-9850
Practice Address - Fax:714-636-1248
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATHWAY MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-25
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0100560Medicaid
CAGR0100561Medicaid
CAGR0100561Medicaid
CAW18076BMedicare PIN