Provider Demographics
NPI:1285699793
Name:PENINSULA PATHOLOGISTS MEDICAL GROUP INC.
Entity type:Organization
Organization Name:PENINSULA PATHOLOGISTS MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALONZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-616-2950
Mailing Address - Street 1:383 E GRAND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-6234
Mailing Address - Country:US
Mailing Address - Phone:650-616-2951
Mailing Address - Fax:
Practice Address - Street 1:1783 EL CAMINO REAL
Practice Address - Street 2:PATHOLOGY DEPT
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3205
Practice Address - Country:US
Practice Address - Phone:650-696-5611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF331997207U00000X, 207ZC0500X, 207ZD0900X
207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Single Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Single Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0030573Medicaid
CAGR0030572Medicaid
CAGR0030575Medicaid
CALAB27269FMedicaid
CAGR0030570Medicaid
CAZZZ14038ZMedicare PIN
CAZZZ16742ZMedicare PIN
CAZZZ15908ZMedicare ID - Type Unspecified
CAGR0030575Medicaid
CAZZZ14039ZMedicare PIN