Basic Information
| Provider Information | |||||||||
| NPI: | 1588712285 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UCSF DEPARTMENT OF LABORATORY MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1635 DIVISADERO ST | ||||||||
| Address2: | SUITE 625, BOX 1821 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941430001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154764029 | ||||||||
| FaxNumber: | 4154764150 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 PARNASSUS AVE | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941432204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154761000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 05/26/2011 | ||||||||
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| AuthorizedOfficialLastName: | REIN | ||||||||
| AuthorizedOfficialFirstName: | DAVE | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4154764003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF CALIFORNIA SAN FRANCISCO MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | 220000091 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 05D0594684 | 01 | CA | CLIA | OTHER | 05D1024215 | 01 | CA | CLIA | OTHER | 05D0643676 | 01 | CA | CLIA | OTHER |