Basic Information
| Provider Information | |||||||||
| NPI: | 1548875198 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONTRA COSTA PATHOLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1440 | ||||||||
| Address2: | |||||||||
| City: | SUISUN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945854440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109640458 | ||||||||
| FaxNumber: | 5109640476 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 SULLIVAN AVE | ||||||||
| Address2: | |||||||||
| City: | DALY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940152200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252703575 | ||||||||
| FaxNumber: | 9252703589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2020 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHIHABI | ||||||||
| AuthorizedOfficialFirstName: | NADER | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING/ CODING MANA | ||||||||
| AuthorizedOfficialTelephone: | 5109640458 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
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 | GR0060540 | 05 | CA | MEDICAID |