Healthcare Provider Details

I. General information

NPI: 1659664654
Provider Name (Legal Business Name): LOMA LINDA UNIVERSITY PATHOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28062 BAXTER RD
MURRIETA CA
92563-1401
US

IV. Provider business mailing address

PO BOX 1740
LOMA LINDA CA
92354-0240
US

V. Phone/Fax

Practice location:
  • Phone: 951-290-4580
  • Fax: 951-290-4932
Mailing address:
  • Phone: 909-558-5170
  • Fax: 909-793-8728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License Number05D2021238
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number05D2021238
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number05D2021238
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number05D2021238
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207ZM0300X
TaxonomyMedical Microbiology Physician
License Number05D2021238
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number05D2021238
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License Number05D2021238
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number05D2021238
License Number StateCA
# 9
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number05D2021238
License Number StateCA

VIII. Authorized Official

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