Healthcare Provider Details

I. General information

NPI: 1982863783
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43112 N 15TH ST
LANCASTER CA
93534-6219
US

IV. Provider business mailing address

393 E WALNUT ST 3RD FLOOR, PHR GROUP & PROVIDER ENROLLMENT
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 661-726-2279
  • Fax:
Mailing address:
  • Phone: 626-405-7914
  • Fax: 626-406-4600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: DR. RAMIN DAVIDOFF
Title or Position: EXECUTIVE MEDICAL DIRECTOR
Credential:
Phone: 877-608-0044