Basic Information
| Provider Information | |||||||||
| NPI: | 1255393435 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN LABORATORIES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WESTERN LABORATORY MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 MOWRY AVE | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945381716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107971111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 01/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | TSCHETTER | ||||||||
| AuthorizedOfficialFirstName: | CLIFFORD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5107971111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | GR0014623 | 05 | CA | MEDICAID |