Healthcare Provider Details

I. General information

NPI: 1053473173
Provider Name (Legal Business Name): SANTA MONICA ORTHOPAEDIC GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 20TH ST 150
SANTA MONICA CA
90404-2050
US

IV. Provider business mailing address

1301 20TH ST 150
SANTA MONICA CA
90404-2050
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-2663
  • Fax:
Mailing address:
  • Phone: 310-829-2663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: RONALD J GOWEY
Title or Position: PRESIDENT
Credential: MD
Phone: 310-829-2663