MEDICARE: SAN DIMAS SURGICAL MEDICAL CENTER INSTITUTE 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	261Q00000X	Clinic/Center	FNP31533	CA

General Provider Information

NPI Number	:	1407040843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN DIMAS SURGICAL MEDICAL CENTER INSTITUTE INC.

Provider Business Mailing Address
First Line	:	221 N SAN DIMAS AVE
Second Line	:	SUITE 200
City	:	SAN DIMAS
State	:	CA
Zip	:	91773-2664
Country	:	US
Telephone Number	:	909-592-0142
Fax Number	:	909-592-0339

Provider Business Practice Location Address
First Line	:	221 N SAN DIMAS AVE
Second Line	:	SUITE 200
City	:	SAN DIMAS
State	:	CA
Zip	:	91773-2664
Country	:	US
Telephone Number	:	909-592-0142
Fax Number	:	909-592-0339

Authorized Official
Title or Position	:	PRESIENT
Name	:	DR. ALEXANDER SOROKURS
Credential	:	M.D.
Telephone Number	:	909-592-0142

Provider Enumeration Date	:	08/29/2007
Last Update Date	:	07/08/2008

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