Provider Demographics
NPI:1518382407
Name:HUNTINGTON REPRODUCTIVE CENTER MEDICAL GROUP, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:HUNTINGTON REPRODUCTIVE CENTER MEDICAL GROUP, A MEDICAL CORPORATION
Other - Org Name:HRC FERTILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & SHAREHOLDER
Authorized Official - Prefix:
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOLB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-440-6191
Mailing Address - Street 1:333 S ARROYO PKWY
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2515
Mailing Address - Country:US
Mailing Address - Phone:626-440-9161
Mailing Address - Fax:626-440-0138
Practice Address - Street 1:333 S ARROYO PKWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2515
Practice Address - Country:US
Practice Address - Phone:626-440-9161
Practice Address - Fax:626-440-0138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-28
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF4964291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1407826423Medicare UPIN
CA1023088689Medicare UPIN
CA1124099783Medicare UPIN