MEDICARE: GLENDALE PATHOLOGY ASSOCIATES MEDICAL GROUP OF GLENDALE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician		CA

General Provider Information

NPI Number	:	1053305797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENDALE PATHOLOGY ASSOCIATES MEDICAL GROUP OF GLENDALE

Provider Business Mailing Address
First Line	:	5700 SOUTHWYCK BLVD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43614-1509
Country	:	US
Telephone Number	:	800-288-8325
Fax Number	:	419-866-5453

Provider Business Practice Location Address
First Line	:	1509 WILSON TER
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91206-4007
Country	:	US
Telephone Number	:	818-409-8000
Fax Number	:	323-265-5086

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHELE COSGROVE
Credential	:	M.D.
Telephone Number	:	818-409-8000

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	12/01/2023

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