Provider Demographics
NPI:1811018948
Name:CORVALAN UROLOGY MEDICAL CENTER
Entity Type:Organization
Organization Name:CORVALAN UROLOGY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:CORVALAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-500-0417
Mailing Address - Street 1:800 FAIRMOUNT AVE STE 420
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3154
Mailing Address - Country:US
Mailing Address - Phone:818-500-0417
Mailing Address - Fax:626-440-9178
Practice Address - Street 1:800 FAIRMOUNT AVE STE 420
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3154
Practice Address - Country:US
Practice Address - Phone:818-500-0417
Practice Address - Fax:626-440-9178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25561174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ66096ZOtherBLUE SHIELD
CA00A255610Medicaid
CAZZZ66096ZOtherBLUE SHIELD
CAA25561AMedicare ID - Type Unspecified