1649337221 NPI number — SOUTH COAST MEDICAL GROUP FAMILY AND SPORTS MEDICINE

Table of content: (NPI 1649337221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649337221 NPI number — SOUTH COAST MEDICAL GROUP FAMILY AND SPORTS MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH COAST MEDICAL GROUP FAMILY AND SPORTS MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649337221
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 JOURNEY STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALISO VIEJO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92656-5330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-360-1069
Provider Business Mailing Address Fax Number:
949-389-8968

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 JOURNEY STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALISO VIEJO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92656-5330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-360-1069
Provider Business Practice Location Address Fax Number:
949-389-8968
Provider Enumeration Date:
01/02/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GHERARDINI
Authorized Official First Name:
JOHNNA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
949-360-1069

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1619061397 . This is a "JOHN CHENG, MD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598723058 . This is a "ARCHANNA BHOGILL, MD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1861586554 . This is a "SHANNON O'CONNOR, MD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1932284478 . This is a "ERIC CLARK, MD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".