Healthcare Provider Details

I. General information

NPI: 1730110495
Provider Name (Legal Business Name): SOUTHLAND RENAL MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 E. SOUTH STREET SUITE 308
LONG BEACH CA
90805-4598
US

IV. Provider business mailing address

PO BOX 879
LAKEWOOD CA
90714-0879
US

V. Phone/Fax

Practice location:
  • Phone: 562-630-3111
  • Fax: 562-630-3107
Mailing address:
  • Phone: 562-630-3111
  • Fax: 562-630-3107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA46344
License Number StateCA

VIII. Authorized Official

Name: DR. AVEDIK SEMERJIAN
Title or Position: PRESIDENT
Credential: MD, FACP, FASN
Phone: 562-630-3111