MEDICARE: DR. GERALD M. POHOST MD

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	207RC0000X	Cardiovascular Disease Physician	G86422	CA
2	207U00000X	Nuclear Medicine Physician	G84622	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P01016324	OTHER	CA	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ68624Y	OTHER	CA	BLUE SHIELD
2	1871534636	OTHER	CA	BLUE CROSS

General Provider Information

NPI Number	:	1871534636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GERALD M. POHOST MD

Provider Business Mailing Address
First Line	:	2200 NORTH MAYFAIR ROAD
Second Line	:	SUITE 200
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-2252
Country	:	US
Telephone Number	:	414-258-9511
Fax Number	:	414-607-3946

Provider Business Practice Location Address
First Line	:	1505 WILSON TERRACE
Second Line	:	SUITE 150
City	:	GLENDALE
State	:	CA
Zip	:	61206-4007
Country	:	US
Telephone Number	:	818-409-3501
Fax Number	:	818-956-7680

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2006
Last Update Date	:	05/24/2012

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Directions to “ DR. GERALD M. POHOST MD” Practice Location

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