MEDICARE: BAKERSFIELD PATHOLOGY MEDICAL GROUP

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	207ZC0500X	Cytopathology Physician
2	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GR0092490	OTHER	CA	DHS GROUP ID
2	ZZZ16224Z	OTHER	CA	BLUE SHIELD GROUP ID

General Provider Information

NPI Number	:	1114996345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAKERSFIELD PATHOLOGY MEDICAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 10076
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91410-0076
Country	:	US
Telephone Number	:	805-578-8300
Fax Number	:	805-578-8950

Provider Business Practice Location Address
First Line	:	2615 EYE ST
Second Line	:
City	:	BAKERSFIELD
State	:	CA
Zip	:	93301-2006
Country	:	US
Telephone Number	:	661-336-0622
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LILIBETH GUINTO-MIRANDA
Credential	:	M.D.
Telephone Number	:	661-336-0622

Provider Enumeration Date	:	03/17/2006
Last Update Date	:	11/20/2012

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