Provider Demographics
NPI:1962417493
Name:SOUTHERN CALIFORNIA ORTHOPAEDIC SPECIALISTS MEDICAL GROUP
Entity type:Organization
Organization Name:SOUTHERN CALIFORNIA ORTHOPAEDIC SPECIALISTS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:G
Authorized Official - Last Name:GOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-354-7270
Mailing Address - Street 1:3838 SHERMAN DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-4001
Mailing Address - Country:US
Mailing Address - Phone:951-354-7270
Mailing Address - Fax:951-354-0625
Practice Address - Street 1:3838 SHERMAN DR
Practice Address - Street 2:SUITE 2
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-4001
Practice Address - Country:US
Practice Address - Phone:951-354-7270
Practice Address - Fax:951-354-0625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX IDENTIFICATION NUMBER
=========OtherTIN
CABBB11937BMedicare UPIN