Basic Information
Provider Information | |||||||||
NPI: | 1881837060 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PIH HEALTH WHITTIER HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PRESBYTERIAN INTERCOMMUNITY HOSPITAL, INC. | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12401 WASHINGTON BLVD | ||||||||
Address2: |   | ||||||||
City: | WHITTIER | ||||||||
State: | CA | ||||||||
PostalCode: | 906021006 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5626980811 | ||||||||
FaxNumber: | 5626986238 | ||||||||
Practice Location | |||||||||
Address1: | 12455 WASHINGTON BLVD | ||||||||
Address2: |   | ||||||||
City: | WHITTIER | ||||||||
State: | CA | ||||||||
PostalCode: | 906021006 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5626980811 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2009 | ||||||||
LastUpdateDate: | 06/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PONCE (AKA CARLSON) | ||||||||
AuthorizedOfficialFirstName: | SUE | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | SPECIAL PROJECTS | ||||||||
AuthorizedOfficialTelephone: | 5626980811 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PRESBYTERIAN INTERCOMMUNITY HOSPITAL, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
ID | Type | State | Issuer | Description | HSC30169F | 05 | CA |   | MEDICAID |