Provider Demographics
NPI:1487958518
Name:SOUTH COAST MEDICAL GROUP
Entity type:Organization
Organization Name:SOUTH COAST MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOHNNA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GHERARDINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-360-1069
Mailing Address - Street 1:5 JOURNEY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-5336
Mailing Address - Country:US
Mailing Address - Phone:949-360-1069
Mailing Address - Fax:949-389-8969
Practice Address - Street 1:5 JOURNEY
Practice Address - Street 2:SUITE 130
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656
Practice Address - Country:US
Practice Address - Phone:949-360-1069
Practice Address - Fax:949-389-8969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 20003261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care