Provider Demographics
NPI:1154371623
Name:SAN GABRIEL VALLEY PERINATAL MEDICAL GROUP, INC
Entity type:Organization
Organization Name:SAN GABRIEL VALLEY PERINATAL MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:O
Authorized Official - Last Name:AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-337-4425
Mailing Address - Street 1:1135 S SUNSET AVE
Mailing Address - Street 2:STE 402
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3938
Mailing Address - Country:US
Mailing Address - Phone:626-337-4425
Mailing Address - Fax:626-337-4606
Practice Address - Street 1:1135 S SUNSET AVE
Practice Address - Street 2:STE 402
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3938
Practice Address - Country:US
Practice Address - Phone:626-337-4425
Practice Address - Fax:626-337-4606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG71304OtherBRENDA ROSS, M.D.
CA00G794030Medicaid
CA00A507640Medicaid
CAG71304OtherBRENDA ROSS, M.D.
CAWA35255JMedicare PIN
CAWA35255HMedicare PIN
CAW10738DMedicare PIN
CAE98639Medicare UPIN
CAA27726Medicare UPIN
CAW10738Medicare PIN
CAH31677Medicare UPIN
CAW10738AMedicare PIN
CAA92490Medicare UPIN
CAG73973Medicare UPIN
CA00A507640Medicaid
CAWA35255IMedicare PIN
CAW10738CMedicare PIN
CAW10738BMedicare PIN
CAE67711Medicare UPIN
CA00G794030Medicaid