Healthcare Provider Details

I. General information

NPI: 1235501636
Provider Name (Legal Business Name): USC CARUSO DEPARTMENT, OTOLARYNGOLOGY-HEAD AND NECK SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2015
Last Update Date: 10/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1983 MARENGO ST
LOS ANGELES CA
90033-1370
US

IV. Provider business mailing address

1540 ALCAZAR ST SUITE 204M
LOS ANGELES CA
90089-0080
US

V. Phone/Fax

Practice location:
  • Phone: 323-409-5070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA138856
License Number StateCA

VIII. Authorized Official

Name: CAITLIN BERTELSEN
Title or Position: RESIDENT PHYSICIAN
Credential: M.D.
Phone: 323-226-7315