MEDICARE: SOUTHLAND RENAL MEDICAL GROUP, INC.

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	207RN0300X	Nephrology Physician	A46344	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205969748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHLAND RENAL MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	3300 E. SOUTH STREET
Second Line	:	SUITE 308
City	:	LONG BEACH
State	:	CA
Zip	:	90805-4598
Country	:	US
Telephone Number	:	562-630-3111
Fax Number	:	562-630-3107

Provider Business Practice Location Address
First Line	:	4152 KATELLA AVE STE 201
Second Line	:
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-6608
Country	:	US
Telephone Number	:	562-630-3111
Fax Number	:	562-630-3107

Authorized Official
Title or Position	:	SECRETARY
Name	:	AVEDIK SEMERJIAN
Credential	:	MD
Telephone Number	:	562-630-3111

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	07/08/2024

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