Provider Demographics
NPI:1770667586
Name:PHYSICIANS SERVICE LABORATORY
Entity Type:Organization
Organization Name:PHYSICIANS SERVICE LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING RADIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:BLAINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-560-1862
Mailing Address - Street 1:5101 E FLORENCE AVE
Mailing Address - Street 2:2
Mailing Address - City:BELL
Mailing Address - State:CA
Mailing Address - Zip Code:90201-3801
Mailing Address - Country:US
Mailing Address - Phone:323-560-1862
Mailing Address - Fax:323-560-7580
Practice Address - Street 1:5101 E FLORENCE AVE
Practice Address - Street 2:2
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-3801
Practice Address - Country:US
Practice Address - Phone:323-560-1862
Practice Address - Fax:323-560-7580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA287102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A287100Medicaid
CA222583422OtherBLUE SHIELD
CA222583422OtherBLUE SHIELD
CA00A287100Medicaid