MEDICARE: UNIVERSITY OF SOUTHERN CALIFORNIA

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	291U00000X	Clinical Medical Laboratory

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	690000015	OTHER	CA	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	05D1033784	OTHER	CA	CLIA NUMBER
3	CLF332197	OTHER		STATE LIC

General Provider Information

NPI Number	:	1467658849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY OF SOUTHERN CALIFORNIA

Provider Business Mailing Address
First Line	:	PO BOX 31309
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-0309
Country	:	US
Telephone Number	:	323-442-1156
Fax Number	:

Provider Business Practice Location Address
First Line	:	2011 ZONAL AVE
Second Line	:	HRM 308 AND 310
City	:	LOS ANGELES
State	:	CA
Zip	:	90089-0110
Country	:	US
Telephone Number	:	323-442-1156
Fax Number	:

Authorized Official
Title or Position	:	SR VP ADMINISTRATION
Name	:	MR. TODD DICKEY
Credential	:
Telephone Number	:	213-740-8184

Provider Enumeration Date	:	06/22/2007
Last Update Date	:	04/30/2015

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Directions to “UNIVERSITY OF SOUTHERN CALIFORNIA ” Practice Location

Language	Start Address	Practice Location

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