Provider Demographics
NPI:1013035864
Name:ST. JOSEPH PULMONARY DIAGNOSTIC MEDICAL GROUP
Entity Type:Organization
Organization Name:ST. JOSEPH PULMONARY DIAGNOSTIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TABACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-972-2626
Mailing Address - Street 1:PO BOX 1551
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91209-1551
Mailing Address - Country:US
Mailing Address - Phone:818-972-2626
Mailing Address - Fax:818-842-5145
Practice Address - Street 1:501 S BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4809
Practice Address - Country:US
Practice Address - Phone:818-972-2626
Practice Address - Fax:818-842-5145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0049980Medicaid
HW7980Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER