Provider Demographics
NPI:1386807246
Name:INTERSCOPE PATHOLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:INTERSCOPE PATHOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:BRICKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-992-7848
Mailing Address - Street 1:21114 VANOWEN ST
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-2821
Mailing Address - Country:US
Mailing Address - Phone:818-992-7848
Mailing Address - Fax:818-992-7943
Practice Address - Street 1:21114 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-2811
Practice Address - Country:US
Practice Address - Phone:818-992-7848
Practice Address - Fax:818-992-7943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF3199291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0700248OtherMEDICARE/CLIA
CAZZZ59323ZMedicaid