Healthcare Provider Details

I. General information

NPI: 1457398505
Provider Name (Legal Business Name): LOMA LINDA UNIVERSITY PATHOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11370 ANDERSON ST SUITE 2960
LOMA LINDA CA
92354-3450
US

IV. Provider business mailing address

PO BOX 1740
LOMA LINDA CA
92354-0240
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-2304
  • Fax: 909-558-3905
Mailing address:
  • Phone: 909-558-2304
  • Fax: 909-558-3905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL HERMANN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 909-558-5175