=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689203374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN CALIFORNIA INTERNISTS MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2020
-----------------------------------------------------
Last Update Date | 04/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1713 E WALNUT ST
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91106-1611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-482-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1713 E WALNUT ST
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91106-1611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-482-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GREGOR PARONIAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 818-482-5500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------