Basic Information
Provider Information | |||||||||
NPI: | 1982863783 | ||||||||
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 FLOOR, PHR GROUP & PROVIDER ENROLLMENT | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911880001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6264057914 | ||||||||
FaxNumber: | 6264064600 | ||||||||
Practice Location | |||||||||
Address1: | 43112 N 15TH ST | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | CA | ||||||||
PostalCode: | 935346219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6617262279 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2008 | ||||||||
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: |   | ||||||||
NPICertificationDate: | 05/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X |   |   | Y |   | Managed Care Organizations | Health Maintenance Organization |   |
No ID Information.