Healthcare Provider Details

I. General information

NPI: 1669790812
Provider Name (Legal Business Name): USC DEPARTMENT OF SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 SAN PABLO ST SUITE 514
LOS ANGELES CA
90033-5320
US

IV. Provider business mailing address

1510 SAN PABLO ST SUITE 514
LOS ANGELES CA
90033-5320
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-9058
  • Fax: 323-442-5803
Mailing address:
  • Phone: 323-442-9058
  • Fax: 323-442-5803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code284300000X
TaxonomySpecial Hospital
License NumberF 5615
License Number StateCA

VIII. Authorized Official

Name: DR. JEFFREY A. HAGEN
Title or Position: DIVISION CHIEF
Credential: MD
Phone: 323-442-9058