Provider Demographics
NPI:1134223415
Name:REDLANDS PATHOLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:REDLANDS PATHOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:909-792-9197
Mailing Address - Street 1:8401 JACK FINNEY BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402-3017
Mailing Address - Country:US
Mailing Address - Phone:800-945-2455
Mailing Address - Fax:770-776-5782
Practice Address - Street 1:350 TERRACINA BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4850
Practice Address - Country:US
Practice Address - Phone:909-792-9197
Practice Address - Fax:909-792-1022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0044310Medicaid
CAZZZ22734ZOtherBLUE SHIELD
CAZZZ22734ZOtherBLUE SHIELD
CA=========OtherBLUE CROSS