=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467536409
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN CALIFORNIA MEDICAL GASTROENTEROLOGY GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2006
-----------------------------------------------------
Last Update Date | 05/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 20TH ST 280
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90404-2050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-829-6789
-----------------------------------------------------
Fax | 310-315-0204
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 20TH ST 280
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90404-2050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-829-6789
-----------------------------------------------------
Fax | 310-315-0204
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THOMAS L KUN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 310-829-0045
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------