MEDICARE: SOUTHLAND MED 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
1	207R00000X	Internal Medicine Physician	G18820	CA

General Provider Information

NPI Number	:	1679707822
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHLAND MED GROUP

Provider Business Mailing Address
First Line	:	1804 GARNET AVE
Second Line	:	SUITE 461
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-3352
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1804 GARNET AVE
Second Line	:	SUITE 461
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-3352
Country	:	US
Telephone Number	:	619-788-4570
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MICHAEL B BUNIM
Credential	:	MD
Telephone Number	:	619-788-4570

Provider Enumeration Date	:	05/02/2009
Last Update Date	:	09/15/2009

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Directions to “SOUTHLAND MED GROUP ” Practice Location

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