Provider Demographics
NPI:1295746394
Name:GREATER LOS ANGELES ONCOLOGY MEDICAL CORPORATION
Entity type:Organization
Organization Name:GREATER LOS ANGELES ONCOLOGY MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:RUNDALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-353-0610
Mailing Address - Street 1:1626 W TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-5027
Mailing Address - Country:US
Mailing Address - Phone:213-353-0610
Mailing Address - Fax:213-353-4802
Practice Address - Street 1:1626 W TEMPLE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5027
Practice Address - Country:US
Practice Address - Phone:213-353-0610
Practice Address - Fax:213-353-4802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DB1410OtherRAILROAD MEDICARE
CAGR0086530Medicaid
CAGR0086531Medicaid
CAZZZ08485ZOtherBLUE SHIELD
CB2861OtherRAILROAD MEDICARE
CAGR0086533Medicaid
CAGR0086534Medicaid
CAGR0086534Medicaid
CAW14720GMedicare ID - Type Unspecified
CAW14720Medicare ID - Type Unspecified
CAGR0086533Medicaid