Basic Information
| Provider Information | |||||||||
| NPI: | 1124269717 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 393 E WALNUT ST | ||||||||
| Address2: | 3RD FLOOR PHR GROUP & PROVIDER ENROLLMENT | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911880001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264057914 | ||||||||
| FaxNumber: | 6264054600 | ||||||||
| Practice Location | |||||||||
| Address1: | 4580 ELECTRONICS PL | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900391008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185025141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2009 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | DAVIDOFF | ||||||||
| AuthorizedOfficialFirstName: | RAMIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8776080044 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.