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NPI Code Detail

MEDICARE: SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP

MEDICARE: SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
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
1291U00000XClinical Medical Laboratory

General Provider Information

NPI Number : 1346328853
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
Provider Business Mailing Address
First Line : 393 E WALNUT ST
Second Line : 3RD FL PHR GROUP & PROVIDER ENROLLMENT
City : PASADENA
State : CA
Zip : 91188-0001
Country : US
Telephone Number : 626-405-7914
Fax Number : 626-405-4600
Provider Business Practice Location Address
First Line : 4580 ELECTRONICS PL
Second Line :
City : LOS ANGELES
State : CA
Zip : 90039-1008
Country : US
Telephone Number : 818-502-5940
Fax Number :
Authorized Official
Title or Position : EXECUTIVE MEDICAL DIRECTOR
Name : RAMIN DAVIDOFF
Credential : M.D.
Telephone Number : 877-608-0044
Provider Enumeration Date : 11/01/2006
Last Update Date : 11/02/2021

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