Provider Demographics
NPI:1730119553
Name:AFFILIATED PATHOLOGISTS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:AFFILIATED PATHOLOGISTS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEBREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-225-3220
Mailing Address - Street 1:20001 S RANCHO WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO DOMINGUEZ
Mailing Address - State:CA
Mailing Address - Zip Code:90220-6318
Mailing Address - Country:US
Mailing Address - Phone:310-225-3244
Mailing Address - Fax:310-698-7040
Practice Address - Street 1:20001 S RANCHO WAY
Practice Address - Street 2:
Practice Address - City:RANCHO DOMINGUEZ
Practice Address - State:CA
Practice Address - Zip Code:90220-6318
Practice Address - Country:US
Practice Address - Phone:310-225-3244
Practice Address - Fax:310-698-7040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0017680Medicaid
CAGR0082250Medicaid
CAGR0085333Medicaid
CAGR0055010Medicaid
CAGR0023280Medicaid
CAGR0085330Medicaid
CAGR0085337Medicaid
CAGR0054410Medicaid
CAGR0076820Medicaid
CAGR0085336Medicaid
ORR156861Medicare PIN
CAGR0085333Medicaid
ORR156862Medicare PIN