=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093009151
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | USC UNIVERSITY HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2011
-----------------------------------------------------
Last Update Date | 06/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1520 SAN PABLO ST SUITE 1000
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90033-5310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-442-5100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1027 N EDINBURGH AVE APT 6
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90046-6023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-560-5773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | FREDRICK A CARLSTON
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 323-442-5100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | NP20259
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------