Basic Information
Provider Information
NPI: 1891873303
EntityType: 2
ReplacementNPI:  
OrganizationName: SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 393 E WALNUT ST
Address2: 3RD FL PHR GROUP & PROVIDER ENROLLMENT
City: PASADENA
State: CA
PostalCode: 911880001
CountryCode: US
TelephoneNumber: 6264057914
FaxNumber: 6264054600
Practice Location
Address1: 11668 SHERMAN WAY
Address2:  
City: N HOLLYWOOD
State: CA
PostalCode: 916055831
CountryCode: US
TelephoneNumber: 8185036800
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/01/2006
LastUpdateDate: 05/27/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: DAVIDOFF
AuthorizedOfficialFirstName: RAMIN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: EXECUTIVE MEDICAL DIRECTOR
AuthorizedOfficialTelephone: 8776080044
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate: 05/27/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
291U00000X  Y LaboratoriesClinical Medical Laboratory 

No ID Information.


Home