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

Table of Contents

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".




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