MEDICARE: OAC SOUTHERN MEDICAL PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician	20A10143	CA

General Provider Information

NPI Number	:	1164777090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAC SOUTHERN MEDICAL PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	23430 HAWTHORNE BLVD
Second Line	:	SUITE 125
City	:	TORRANCE
State	:	CA
Zip	:	90505-4720
Country	:	US
Telephone Number	:	310-373-0555
Fax Number	:	310-373-5655

Provider Business Practice Location Address
First Line	:	3300 W COAST HWY
Second Line	:	SUITE A
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-4007
Country	:	US
Telephone Number	:	949-209-0220
Fax Number	:	949-270-5139

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARYAM RAHIMI
Credential	:	D.O.
Telephone Number	:	310-634-1146

Provider Enumeration Date	:	07/17/2012
Last Update Date	:	07/17/2012

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Directions to “OAC SOUTHERN MEDICAL PROFESSIONAL CORPORATION ” Practice Location

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