Provider Demographics
NPI:1992740450
Name:USC OBSTETRICIANS AND GYNECOLOGISTS, INC.
Entity type:Organization
Organization Name:USC OBSTETRICIANS AND GYNECOLOGISTS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAILA
Authorized Official - Middle Name:I
Authorized Official - Last Name:MUDERSPACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-221-3270
Mailing Address - Street 1:1640 MARENGO ST
Mailing Address - Street 2:SUITE 505
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1036
Mailing Address - Country:US
Mailing Address - Phone:323-221-3270
Mailing Address - Fax:323-225-6284
Practice Address - Street 1:800 FAIRMOUNT AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3150
Practice Address - Country:US
Practice Address - Phone:323-221-3270
Practice Address - Fax:323-225-6284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0056153Medicaid
CAZZZ02683ZOtherBLUE SHILELD
CAGR0056154Medicaid
CAZZZ02127ZOtherBLUE SHIELD
CAZZZ56147ZOtherBLUE SHIELD
CAGR0056151Medicaid
CAZZZ67025ZOtherBLUE SHIELD
CAZZZ67024ZOtherBLUE SHIELD
CAGR0056155Medicaid
CAGR0056152Medicaid
CAGR0056150Medicaid
CAZZZ01352ZOtherBLUE SHIELD
CAGR0056153Medicaid
CAW12043FMedicare ID - Type UnspecifiedMEDICARE
CAGR0056154Medicaid
CAW12043BMedicare ID - Type UnspecifiedMEDICARE
CAGR0056151Medicaid
CAGR0056152Medicaid
CAW12043AMedicare ID - Type UnspecifiedMEDICARE